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Kobayashi S, Miyake S, Shibata T, Matsunaga K, Hata N, Izaki T, Yamamoto T. Risk of Axillary Nerve Injury With Medial Support Screws in Intramedullary Nails: An Anatomical Study. Cureus 2024; 16:e64119. [PMID: 39119375 PMCID: PMC11306812 DOI: 10.7759/cureus.64119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND In recent years, intramedullary nails with medial support screws for proximal humeral fractures have become available. Although these devices have a potential risk of iatrogenic axillary nerve injury, no studies have investigated the anatomical relationship between the medial support screws in the modern intramedullary nail and the axillary nerve. This study aimed to clarify the anatomical relationship between the medial support screws in the intramedullary nail and the axillary nerve. MATERIALS AND METHODS In total, 29 cadaveric shoulders (mean age: 82.6 years old (range: 61-105); 15 males and 14 females) were included in this study. Shoulders within whole-body cadavers were used in all cases. A single proximal humeral nail with medial support screws (ARISTO Proximal Humeral Nail; MDM, Tokyo, Japan) was used. The distance of each medial support screw from the axillary nerve and its branches was measured. RESULTS In two (6.90%) of 29 shoulders, the axillary nerves came into contact with the medial support screws. In the remaining 27 of 29 shoulders (93.1%), the nerves were located proximal to the medial support screws. CONCLUSION Medial support screws in proximal humeral fracture nails had the potential to injure the axillary nerve and its branches.
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Affiliation(s)
- Shunsuke Kobayashi
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Satoshi Miyake
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Terufumi Shibata
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Kei Matsunaga
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Naofumi Hata
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
| | - Teruaki Izaki
- Department of Orthopaedic Surgery, Fukuoka University Chikushi Hospital, Chikushino, JPN
| | - Takuaki Yamamoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, JPN
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Foruria AM. Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement. Curr Rev Musculoskelet Med 2023; 16:457-469. [PMID: 37572239 PMCID: PMC10497484 DOI: 10.1007/s12178-023-09853-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/14/2023]
Abstract
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.
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Affiliation(s)
- Antonio M Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery, Autónoma University, Fundación Jiménez Díaz University Hospital, Avenida Reyes Católicos 2, Madrid, Spain.
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Fu H, Wu J, Wu X. Intramedullary Nail for Treatment of Proximal Humeral Fracture: A Credible Fixation in Comminuted Calcar. Orthop Surg 2023; 15:2007-2015. [PMID: 36514186 PMCID: PMC10432444 DOI: 10.1111/os.13616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Restoration of the medial support is especially important for the treatment of proximal humeral fractures. The objective of this study was to investigate the radiographic and clinical outcomes of intramedullary nail fixation with a special focus on the presence of calcar comminution. METHODS In this retrospective study of patients with displaced proximal humeral fractures that were treated by intramedullary nail between January 2018 and July 2021, fracture morphology and the calcar integrity were noted on preoperative radiographs. Patients were divided into two groups according to calcar integrity. During follow-up, radiological assessment and functional outcome, including the deltoid tuberosity index (DTI), neck shaft angle (NSA), visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, active and passive range of motion, were performed. A Student t-test and univariate logistic regression analysis was used. RESULTS A total of 83 patients (54 female, 29 male) had complete follow-up (average, 12.8 months; range, 10 to 33 months) and functional assessment in our study. The average age was 58.6 years (range, 20 to 89 years). The mean loss of NSA was 4° (range, 0°-12°) and no significant difference was found between two groups (p = 0.27). DTI had an average of 1.50 ± 0.19 (range 1.13-2.04). Patients with intact calcar achieved greater range of forward elevation (129.06 ± 11.91 vs. 121.05 ± 11.97, p = 0.01), and higher SST scores (8.61 ± 1.85 vs. 7.37 ± 2.22, p = 0.02). Two groups showed similar outcomes in VAS, ASES score, and range of abduction. One patient demonstrated a proximal interlocking screw cutting through and osteonecrosis of the humeral head, who underwent a second surgery for screw removal. There were no cases of infection, malunion, nonunion, nerve injury, subacromial impingement, or rotator cuff tear during the study period. CONCLUSION Intramedullary nail can favorably be used to manage proximal humeral fractures with good early radiographic and functional outcomes, even for those with comminuted calcar.
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Affiliation(s)
- Huichao Fu
- Department of Orthopaedic Traumatology, Trauma Center, Shanghai General HospitalShanghaiChina
| | - Jianhong Wu
- Department of Orthopaedic Traumatology, Trauma Center, Shanghai General HospitalShanghaiChina
| | - Xiaoming Wu
- Department of Orthopaedic Traumatology, Trauma Center, Shanghai General HospitalShanghaiChina
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Ott N, Hackl M, Prescher A, Scaal M, Lanzerath F, Müller LP, Wegmann K. The effect of long calcar screws on the primary stability of 3-part, varus impacted proximal humeral fractures compared to short calcar screws: a real fracture simulation study. Arch Orthop Trauma Surg 2022; 143:2485-2491. [PMID: 35635575 PMCID: PMC10110638 DOI: 10.1007/s00402-022-04473-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/27/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Complex proximal humeral fracture ranks among the most common fracture types, especially in elderly patients. In locked plate fixation of proximal humerus fractures, the calcar is deciding for screws providing further medial column support. To date, the biomechanical effect of the length of these calcar screws is not well known. The purpose of this study was to analyze the effect of long calcar screws on fresh frozen prefractured cadaveric specimens. METHODS In the present biomechanical study, 8 pairs of cadaveric proximal humeri were fractured identically using a custom-made fracture simulator. ORIF was performed using a locking plate (PHILOS; Fa. Synthes). The specimens were tested in a biomechanical setup under increased axial load without any calcar screws installed, with short calcar screws and long calcar screws installed. Strain gages (4-wire-120 Ohm, Fa. Vishay) mounted on the locking plate were used to evaluate the fixation strain and to give an estimate for primary stability.. RESULTS The measured strain of the locking plate without calcar screws (804,64 µm/m) at maximum load (200 N) was significantly higher than with short (619,07 µm/m; p = 0.02) or long calcar screws (527,31 µm/m; p = 0.007). Additionally, strain with short calcar screws was noticeably higher in comparison to long calcar screws (619,07 µm/m vs. 527,31 µm/m; p = 0.03). CONCLUSION Use of calcar screws improves the stability of realistically impacted 3-part varus humeral fractures. Long calcar screws that are positioned as close as possible to the joint provide further primary stability compared to short calcar screws. LEVEL OF EVIDENCE Basic science study.
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Affiliation(s)
- Nadine Ott
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
| | - Michael Hackl
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Andreas Prescher
- Institute of Molecular and Cellular Anatomy -Prosektur, RWTH Aachen, Aachen, Germany
| | - Martin Scaal
- Department of Anatomy, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Fabian Lanzerath
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Lars Peter Müller
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Kilian Wegmann
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener Street 62, 50937, Cologne, Germany.,Orthopädische Chirurgie München, OCM Clinic, Steinerstrasse 6, 81369, Munich, Germany
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Zhang H, Hu Y, Chen X, Wang S, Cao L, Dong S, Shi Z, Chen Y, Xiong L, Zhang Y, Zhang D, Yu B, Chen W, Wang Q, Tong P, Liu X, Zhang J, Zhou Q, Niu F, Yang W, Zhang W, Wang Y, Chen S, Jia J, Yang Q, Zhang P, Zhang Y, Miao J, Sun K, Shen T, Yu B, Yang L, Zhang L, Wang D, Liu G, Zhang Y, Su J. Expert consensus on the bone repair strategy for osteoporotic fractures in China. Front Endocrinol (Lausanne) 2022; 13:989648. [PMID: 36387842 PMCID: PMC9643410 DOI: 10.3389/fendo.2022.989648] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Osteoporotic fractures, also known as fragility fractures, are prevalent in the elderly and bring tremendous social burdens. Poor bone quality, weak repair capacity, instability, and high failure rate of internal fixation are main characteristics of osteoporotic fractures. Osteoporotic bone defects are common and need to be repaired by appropriate materials. Proximal humerus, distal radius, tibia plateau, calcaneus, and spine are common osteoporotic fractures with bone defect. Here, the consensus from the Osteoporosis Group of Chinese Orthopaedic Association concentrates on the epidemiology, characters, and management strategies of common osteoporotic fractures with bone defect to standardize clinical practice in bone repair of osteoporotic fractures.
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Affiliation(s)
- Hao Zhang
- Institute of Translational Medicine, Shanghai University, Shanghai, China
- Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yan Hu
- Institute of Translational Medicine, Shanghai University, Shanghai, China
| | - Xiao Chen
- Changhai Hospital, Naval Medical University, Shanghai, China
| | - Sicheng Wang
- Department of Orthopedics, Shanghai Zhongye Hospital, Shanghai, China
| | - Liehu Cao
- Department of Orthopedics, Shanghai Baoshan Luodian Hospital, Shanghai, China
| | - Shiwu Dong
- Department of Biomedical Materials Science, Army Medical University, Chongqing, China
| | - Zhongmin Shi
- Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yanxi Chen
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liming Xiong
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yunfei Zhang
- Tangdu Hospital, Air Force Medical University, Xi'an, China
| | | | - Baoqing Yu
- Department of Orthopedics, Shanghai Pudong Hospital, Shanghai, China
| | - Wenming Chen
- Institute of Biomedical Engineering, Academy for Engineering and Technology, Fudan University, Shanghai, China
| | - Qining Wang
- Department of Advanced Manufacturing and Robotics, College of Engineering, Peking University, Beijing, China
| | - Peijian Tong
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Ximing Liu
- Department of Orthopedics, General Hospital of Central Theater Command, Wuhan, China
| | - Jianzheng Zhang
- Department of Orthopedic Surgery, People's Liberation Army (PLA), Army General Hospital, Beijing, China
| | - Qiang Zhou
- Department of Orthopedics, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Niu
- Department of Orthopedics, The First Hospital of Jilin University, Changchun, China
| | - Weiguo Yang
- Li Ka Shing Faculty of Medicine, Hongkong University, Hong Kong, Hong Kong SAR, China
| | - Wencai Zhang
- Department of Orthopedics, The Third Affiliated Hospital of Guangzhou University of Traditional Chinese medicine (TCM), Guangzhou, China
| | - Yong Wang
- Department of Orthopedics, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Shijie Chen
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jinpeng Jia
- Department of Orthopedics, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Qiang Yang
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
| | - Peng Zhang
- Department of Orthopedics, Shandong Province Hospital, Jinan, China
| | - Yong Zhang
- Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jun Miao
- Department of Orthopedics, Tianjin Hospital, Tianjin, China
| | - Kuo Sun
- Department of Orthopedics, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tao Shen
- Department of Orthopedics, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Bin Yu
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Lei Yang
- Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lei Zhang
- Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Dongliang Wang
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
| | - Guohui Liu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
| | - Yingze Zhang
- Department of Orthopedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
| | - Jiacan Su
- Institute of Translational Medicine, Shanghai University, Shanghai, China
- Changhai Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Dongliang Wang, ; Guohui Liu, ; Yingze Zhang, ; Jiacan Su,
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Dankl L, Schmoelz W, Hoermann R, Euler S. Evaluation of mushroom-shaped allograft for unstable proximal humerus fractures. Arch Orthop Trauma Surg 2022; 142:409-416. [PMID: 33355717 PMCID: PMC8843909 DOI: 10.1007/s00402-020-03715-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/06/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Proximal humerus fractures are common injuries of the elderly. Different treatment options, depending on fracture complexity and stability, have been recommended in the literature. Particularly for varus displaced fractures with a lack of medial support, and patients suffering from osteoporosis, structural allografts can be used to enhance the stability of the construct. An individually shaped allograft has been suggested in the literature and investigated in a clinical setting. However, biomechanical properties have yet to be evaluated. MATERIALS AND METHODS Twenty-four fresh-frozen humeri and 12 femoral heads were obtained, and an unstable three-part fracture of the humeral head was simulated. Fracture fixation was achieved by using a locking plate in both groups. In the test group, a mushroom-shaped allograft was tailored out of a femoral head to individually fit the void inside the humeral head. Specimens were fitted with a 3D motion analysis system and cyclically loaded with a stepwise increasing load magnitude in a varus-valgus bending test until failure or up to a maximum of 10,000 load cycles. RESULTS The mushroom group reached a significantly higher number of load cycles (8342; SD 1,902; CI 7133-9550) compared to the control group (3475; SD 1488; CI 2530-4420; p < 0.001). Additionally, the test group showed significantly higher stiffness values concerning all observational points (p < 0.001). CONCLUSION This mushroom-shaped allograft in combination with a locking plate significantly increased load to failure as well as stiffness of the construct when exposed to varus-valgus bending forces. Therefore, it might be a viable option for surgical treatment of unstable and varus displaced proximal humerus fractures to superiorly prevent loss of reduction and varus collapse.
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Affiliation(s)
- Lukas Dankl
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Werner Schmoelz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Romed Hoermann
- Division Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Simon Euler
- Trauma and Orthopedic Surgery, Sanatorium Kettenbruecke der Barmherzigen Schwestern GmbH, Innsbruck, Austria
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Shin MJ, Kim H, Kim DM, Park D, Jeon IH, Koh KH. Role of inferomedial supporting screws for secondary varus deformity in non-osteoporotic proximal humerus fracture: A biomechanical study. Arch Orthop Trauma Surg 2021; 141:1517-1523. [PMID: 33051712 DOI: 10.1007/s00402-020-03627-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the effect of a medial support screw through a proximal humerus fracture. For this purpose, we verified whether the biomechanics are different according to the position of the screw while using the same number of screws. In addition, we tried to verify whether the insertion of additional inferomedial screws would make a difference in stability. MATERIALS AND METHODS Twenty-four proximal humerus bones were included in the study. A two-part fracture was created and fixed using a locking plate. Cyclic loading and load-to-failure test were applied to three groups: group A (proximal 6 screws + calcar screws), group B (proximal 6 screws), and group C (proximal 4 screws + calcar screws). Interfragmentary gaps were measured following cyclic loading and compared. The failure was defined when the bone breakage or medial gap closing was observed during ultimate failure load applied. The load-to-failure, maximum displacement, stiffness, and yield load were recorded and compared. RESULTS The interfragmentary gap was differently reduced by 0.29 ± 0.14 mm, 0.73 ± 0.25 mm, and 0.53 ± 0.09 mm following 1000 cyclic loading for groups A, B, and C, respectively. The load-to-failure was 945.22 ± 101.02 N, 941.40 ± 148.90 N, and 940.58 ± 91.78 N in groups A, B, and C, respectively. The stiffness of group A (214.76 ± 34.0 N/mm) was superior when compared to that of group C (171.12 ± 23.0 N/mm; p = 0.025). The maximum displacement prior to failure, yield load, showed no significant difference between comparative groups. CONCLUSION Our study did not show any additional biomechanical effects with the use of inferomedial supporting screws in non-osteoporotic proximal humerus fracture, besides making the fracture-plate construct stiff. The role of the inferomedial supporting screw was also unclear. However, the groups that used increased screw fixation and inferomedial screw insertion seemed to be more resistant to cyclic loading.
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Affiliation(s)
- Myung Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hyojune Kim
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong Min Kim
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dongjun Park
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kyoung Hwan Koh
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Tilton M, Lewis GS, Hast MW, Fox E, Manogharan G. Additively manufactured patient-specific prosthesis for tumor reconstruction: Design, process, and properties. PLoS One 2021; 16:e0253786. [PMID: 34260623 PMCID: PMC8279401 DOI: 10.1371/journal.pone.0253786] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 06/12/2021] [Indexed: 01/20/2023] Open
Abstract
Design and processing capabilities of additive manufacturing (AM) to fabricate complex geometries continues to drive the adoption of AM for biomedical applications. In this study, a validated design methodology is presented to evaluate AM as an effective fabrication technique for reconstruction of large bone defects after tumor resection in pediatric oncology patients. Implanting off-the-shelf components in pediatric patients is especially challenging because most standard components are sized and shaped for more common adult cases. While currently reported efforts on AM implants are focused on maxillofacial, hip and knee reconstructions, there have been no reported studies on reconstruction of proximal humerus tumors. A case study of a 9-year-old diagnosed with proximal humerus osteosarcoma was used to develop a patient-specific AM prosthesis for the humerus following tumor resection. Commonly used body-centered cubic (BCC) structures were incorporated at the surgical neck and distal interface in order to increase the effective surface area, promote osseointegration, and reduce the implant weight. A patient-specific prosthesis was fabricated using electron beam melting method from biocompatible Ti-6Al-4V. Both computational and biomechanical tests were performed on the prosthesis to evaluate its biomechanical behavior under varying loading conditions. Morphological analysis of the construct using micro-computed tomography was used to compare the as-designed and as-built prosthesis. It was found that the patient-specific prosthesis could withstand physiologically-relevant loading conditions with minimal permanent deformation (82 μm after 105 cycles) at the medial aspect of the porous surgical neck. These outcomes support potential translation of the patient-specific AM prostheses to reconstruct large bone defects following tumor resection.
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Affiliation(s)
- Maryam Tilton
- Department of Mechanical Engineering, Pennsylvania State University, University Park, Pennsylvania, United States of America
| | - Gregory S. Lewis
- Department of Mechanical Engineering, Pennsylvania State University, University Park, Pennsylvania, United States of America
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, Pennsylvania, United States of America
| | - Michael W. Hast
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Edward Fox
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, Pennsylvania, United States of America
| | - Guha Manogharan
- Department of Mechanical Engineering, Pennsylvania State University, University Park, Pennsylvania, United States of America
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Gardenbroek TJ, Oud S, Formijne Jonkers HA, Goslings JC. Supporting the medial hinge in proximal humerus fractures with an intramedullary plate. Trauma Case Rep 2021; 33:100474. [PMID: 33997224 PMCID: PMC8102799 DOI: 10.1016/j.tcr.2021.100474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2021] [Indexed: 11/19/2022] Open
Abstract
Proximal humerus fractures are common and approximately 20% of displaced fractures may benefit from surgery. A lack of medial support is found to be a predictor of failure after surgical fixation of proximal humerus fractures. The optimal technique for restoring the medial hinge is unclear. We describe two cases of patients with a dislocated 4-part humerus fracture treated with a locking plate and an additional small intramedullary plate to support the medial hinge. This technique is simple and allows for an enhanced stability of the medial hinge during and after surgery.
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Affiliation(s)
| | - Sharon Oud
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | | | - J Carel Goslings
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, the Netherlands
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Kim H, Shin MJ, Kholinne E, Seo J, Ahn D, Kim JW, Koh KH. How Many Proximal Screws Are Needed for a Stable Proximal Humerus Fracture Fixation? Geriatr Orthop Surg Rehabil 2021; 12:2151459321992744. [PMID: 33623724 PMCID: PMC7876747 DOI: 10.1177/2151459321992744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 01/11/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose This biomechanical study investigates the optimal number of proximal screws for stable fixation of a 2-part proximal humerus fracture model with a locking plate. Methods Twenty-four proximal humerus fracture models were included in the study. An unstable 2-part fracture was created and fixed by a locking plate. Cyclic loading and load-to-failure tests were used for the following 4 groups based on the number of screws used: 4-screw, 6-screw, 7-screw, and 9-screw groups. Interfragmentary gaps were measured following cyclic loading and compared. Consequently, the load to failure, maximum displacement, stiffness, and mode of failure at failure point were compared. Results The interfragmentary gaps for the 4-screw, 6-screw, 7-screw, and 9-screw groups were significantly reduced by 0.24 ± 0.09 mm, 0.08 ± 0.06 mm, 0.05 ± 0.01 mm, and 0.03 ± 0.01 mm following 1000 cyclic loading, respectively. The loads to failure were significantly different between the groups with the 7-screw group showing the highest load to failure. The stiffness of the 7-screw group was superior compared with the 6-screw, 9-screw, and 4-screw groups. The maximum displacement before failure showed a significant difference between the comparative groups with the 4-screw group having the lowest value. The 7-screw group had the least structural failure rate (33.3%). Conclusion At least 7 screws would be optimal for proximal fragment fixation of proximal humerus fractures with medial comminution to minimize secondary varus collapse or fixation failure. Level of Evidence Basic science study.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.,Depart of Orthopedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Myung Jin Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Erica Kholinne
- Department of Orthopedic Surgery, Faculty of Medicine, St. Carolus Hospital, Trisakti University, Jakarta, Indonesia
| | | | | | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Kyoung Hwan Koh
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
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11
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Cristofolini L, Ruspi ML, Marras D, Cavallo M, Guerra E. Reconstruction of proximal humeral fractures without screws using a reinforced bone substitute. J Biomech 2020; 115:110138. [PMID: 33288210 DOI: 10.1016/j.jbiomech.2020.110138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 11/25/2022]
Abstract
Multi-fragment fractures are still a challenge: current clinical practice relies on plates and screws. Treatment of fractures of the proximal humerus has the intra-operative risk of articular damage when inserting multiple screws. Distal-varus collapse of the head is a frequent complication in osteoporotic patients. The aim of this biomechanical study was to investigate if an Innovative-cement-technique (the screws are replaced by injection of cement) provides the same or better stability of the reconstructed head compared to the Standard-technique (locking screws). A four-fragment fracture was simulated in twelve pairs of humeri, with removal of part of the cancellous bone to simulate osteoporotic "eggshell" defect. One humerus of each pair was repaired either with a Standard-technique (locking plate, 2 cortical and 6 locking screws), or with the Innovative-cement-technique (injection of a partially-resorbable reinforced bone substitute consisting of PMMA additivated with 26% beta-TCP). Cement injection was performed both in the lab and under fluoroscopic monitoring. The reconstructed specimens were tested to failure with a cyclic force of increasing amplitude. The Innovative-cement-technique withstood a force 3.57 times larger than the contralateral Standard reconstructions before failure started. The maximum force before final collapse for the Innovative-cement-technique was 3.56 times larger than the contralateral Standard-technique. These differences were statistically significant. The Innovative-cement-technique, based on the reinforced bone substitute, demonstrated better biomechanical properties compared to the Standard-technique. These findings, along with the advantage of avoiding the possible complications associated with the locking screws, may help safer and more effective treatment in case of osteoporotic multi-fragment humeral fractures.
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Affiliation(s)
- Luca Cristofolini
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Bologna, Italy.
| | - Maria Luisa Ruspi
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Daniele Marras
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Marco Cavallo
- Shoulder and Elbow Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Enrico Guerra
- Shoulder and Elbow Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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12
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Russo R, Guastafierro A, Rotonda GD, Viglione S, Ciccarelli M, Mortellaro M, Minopoli P, Fiorentino F, Pietroluongo LR. A new classification of impacted proximal humerus fractures based on the morpho-volumetric evaluation of humeral head bone loss with a 3D model. J Shoulder Elbow Surg 2020; 29:e374-e385. [PMID: 32573449 DOI: 10.1016/j.jse.2020.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study aimed to classify the pathomorphology of impacted proximal humeral fractures according to the control volume theory, with the intention to introduce a severity index to support surgeons in decision making. METHODS In total, 50 proximal humeral fractures were randomly selected from 200 medical records of adult patients treated from 2009 to 2016. Four nonindependent observers used 2 different imaging modalities (computed tomography scans plus volume rendering; 3D model) to test the classification reliability. A fracture classification system was created according to the control volume theory to provide simple and understandable patterns that would help surgeons make quick assessments. The impacted fractures table was generated based on an evaluation of the calcar condition, determined by the impairment of a defined volumetric area under the cephalic cup and the humeral head malposition. In addition to the main fracture pattern, the comminution degree (low, medium, high), providing important information on fracture severity, could also be evaluated. RESULTS From 3D imaging, the inter- and intraobserver reliability revealed a k value (95% confidence interval) of 0.55 (0.50-0.60) and 0.91 (0.79-1.00), respectively, for the pattern code, and 0.52 (0.43-0.76) and 0.91 (0.56-0.96), respectively, for the comminution degree. CONCLUSIONS The new classification provides a useful synoptic framework for identifying complex fracture patterns. It can provide the surgeon with useful information for fracture analysis and may represent a good starting point for an automated system.
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Affiliation(s)
- Raffaele Russo
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta, Italy.
| | | | | | - Stefano Viglione
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta, Italy
| | - Michele Ciccarelli
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta, Italy
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13
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Cristofolini L, Morellato K, Cavallo M, Guerra E. Reconstruction of proximal humeral fractures with a reduced number of screws and a reinforced bone substitute. Med Eng Phys 2020; 82:97-103. [DOI: 10.1016/j.medengphy.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 02/04/2023]
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Dheenadhayalan J, Prasad VD, Devendra A, Rajasekaran S. Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases. J Orthop Surg (Hong Kong) 2020; 27:2309499019848166. [PMID: 31104562 DOI: 10.1177/2309499019848166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The purpose of this study is to analyze the radiological and functional outcome of complex proximal humerus fractures treated by open reduction and plate fixation, and how radiological parameters correlate with functional outcome. DESIGN Retrospective study. SETTING Level-1 trauma center. PATIENTS/METHODS One hundred twenty-seven patients were analyzed, with a mean follow-up of 5 (3-7) years. OUTCOME MEASUREMENTS Radiological parameters studied were neck-shaft angle (NSA), greater tuberosity (GT) to articular surface (AS) distance, medial hinge reduction, and presence (or absence) of calcar screw. Functional outcome evaluated by DASH and Constant-Murley (C-M) score. RESULTS The mean age is 53.8 years. All patients had a union in 14 (12-18) weeks. The mean NSA is 135° (112-155°). One hundred and thirteen patients with an NSA of >120° had a good functional outcome. Fourteen patients with NSA ≤120° had shoulder abduction <90°. The mean GT to AS distance is 7.2 mm (-2 to 16). The superior displacement of GT above AS is associated with abduction of <90° (16 patients). The mean medial gap is 3 mm (0-17). In 14 patients with a medial gap of >4 mm and without calcar screw, varus collapse is observed. All patients had a good outcome on DASH score and 122 patients had good to excellent outcome on C-M score. Five patients with poor outcome on C-M score had NSA <120° and displacement of GT above AS. CONCLUSION Radiographic indicators for poor outcome are varus angulation with NSA <120°, superior displacement of GT above AS, the presence of medial gap >4 mm, and absence of calcar specific screw. This "terrible triad" of proximal humerus fracture should be avoided during operative fixation.
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Affiliation(s)
- J Dheenadhayalan
- 1 Division of Orthopaedics and Trauma, Ganga Hospital, Coimbatore, India
| | - V Durga Prasad
- 1 Division of Orthopaedics and Trauma, Ganga Hospital, Coimbatore, India
| | - A Devendra
- 1 Division of Orthopaedics and Trauma, Ganga Hospital, Coimbatore, India
| | - S Rajasekaran
- 2 Division of Orthopaedics, Trauma and Spine Surgery, Ganga Hospital, Coimbatore, India
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15
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邢 飞, 段 鑫, 刘 明, 黄 富, 项 舟. [Research progress in treatment of proximal humeral fracture with fibular allograft and locking plate]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:260-265. [PMID: 32030961 PMCID: PMC8171967 DOI: 10.7507/1002-1892.201906104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/21/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review the research progress in the treatment of proximal humeral fractures with fibular allograft and locking plate. METHODS The literature about the treatment of proximal humeral fractures with fibular allograft and locking plate was reviewed and analyzed from the aspects such as the biomechanics, imaging prognosis, and clinical prognosis. RESULTS Fibular allograft and locking plate can provide effective medial support for proximal humeral fracture and increase the strength of internal fixation system. Compared with locking plate, fibular allograft combined with locking plate can maintain better humeral neck-shaft angle and the humeral head height after operation in the treatment of proximal humeral fractures, and has better shoulder mobility and shoulder joint function, and does not increase the risk of complications. CONCLUSION Fibular allograft combined with locking plate may be a new and effective treatment for proximal humeral fractures. However, the long-term follow-up results are insufficient, the final outcome of fibula is uncertain, and the long-term potential adverse reactions caused by this treatment are still indefinite.
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Affiliation(s)
- 飞 邢
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 鑫 段
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 明 刘
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 富国 黄
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - 舟 项
- 四川大学华西医院骨科(成都 610041)Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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16
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Padegimas EM, Chang G, Namjouyan K, Namdari S. Failure to restore the calcar and locking screw cross-threading predicts varus collapse in proximal humerus fracture fixation. J Shoulder Elbow Surg 2020; 29:291-295. [PMID: 31447284 DOI: 10.1016/j.jse.2019.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/10/2019] [Accepted: 06/18/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Varus collapse is a common failure mode of proximal humerus fracture (PHF) fixation. The purpose of this study was to analyze predictors of varus collapse of PHF after open reduction, internal fixation (ORIF). METHODS All patients who underwent ORIF of a PHF from January 2008 to July 2018 were identified. Known predictors of fixation failure were assessed, including calcar distance, calcar ratio, and calcar restoration. Additionally, the presence of cross-threaded screws was determined. The primary outcome analyzed was varus collapse of the fracture defined as a change in neck shaft angulation to less than 120°. RESULTS There were 112 patients identified who underwent ORIF of a PHF that met inclusion criteria. The population was 75.0% female (84/112), average age was 62.5 ± 10.4 years (range 40.0-87.9), and average body mass index was 28.0 ± 5.5 (17.5-46.4). There were 17 with varus collapse. In 11 of the 17 patients (64.7%), there was screw cross-threading (vs. 31/95 [32.6%] in those that did not collapse); P = .012. In addition, 8 of the 17 (47.1%) did not have restoration of the calcar (vs. 16/95 [16.8%]; P = .005). CONCLUSION This study identifies 2 surgeon-controlled variables that can contribute to varus collapse after ORIF of PHFs. Cross-threading of locking screws and failure to restore the medial calcar can be a function of implant design, surgeon technical skill, and/or bone quality.
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Affiliation(s)
- Eric M Padegimas
- The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Gerard Chang
- The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Kamran Namjouyan
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Surena Namdari
- The Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
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17
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Chen H, Zhu ZG, Li JT, Chang ZH, Tang PF. Finite element analysis of an intramedulary anatomical strut for proximal humeral fractures with disrupted medial column instability: A cohort study. Int J Surg 2019; 73:50-56. [PMID: 31783165 DOI: 10.1016/j.ijsu.2019.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Hua Chen
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China.
| | - Zheng-Guo Zhu
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China
| | - Jian-Tao Li
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China
| | - Zu-Hao Chang
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China
| | - Pei-Fu Tang
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China.
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Zhao L, Qi YM, Yang L, Wang GR, Zheng SN, Wang Q, Liang B, Jiang CZ. Comparison of the Effects of Proximal Humeral Internal Locking System (PHILOS) Alone and PHILOS Combined with Fibular Allograft in the Treatment of Neer Three- or Four-part Proximal Humerus Fractures in the Elderly. Orthop Surg 2019; 11:1003-1012. [PMID: 31762222 PMCID: PMC6904636 DOI: 10.1111/os.12564] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/16/2019] [Accepted: 10/08/2019] [Indexed: 01/28/2023] Open
Abstract
Objective To compare and analyze the clinical outcomes of the proximal humeral internal locking system (PHILOS) alone and the PHILOS combined with fibular allograft in the treatment of Neer three‐ and four‐part proximal humerus fractures (PHF) in the elderly. Methods From January 2014 to January 2018, a total of 42 elderly patients with Neer three‐ or four‐part PHF admitted to our hospital were randomly divided into observation group and control group, with 21 patients in each group. The observation group was treated with the PHILOS combined with fibular allograft. The control group was treated with the PHILOS alone. Perioperative parameters and fracture classification were recorded in the two groups. Function results were assessed by Visual Analog Scale (VAS), Constant‐Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, and the Disability of Arm‐Shoulder‐Hand (DASH) score. Radiological results were evaluated using the neck‐shaft angle (NSA) and humeral head height (HHH), and complications were also recorded in each group. Results There were no significant differences between the two groups in terms of preoperative status, age, gender, cause of trauma, fracture site, and fracture classification. The average follow‐up time was 12 months. At the last follow‐up, the VAS and DASH observation groups were lower than the control group, and there was significant difference between the two groups (P < 0.05). The CMS and ASES were higher in the observation group than the control group, and there was significant difference between the two groups (P < 0.05). The mean difference in the NSA and HHH were lower in the observation group than the control group, and there was a significant difference between the two groups (P < 0.05). There was one postoperative complication in the observation group, which was humeral head avascular necrosis (AVN). There were seven postoperative complications in the control group, including three cases of humeral head collapse and three cases of screw cutout and one case of humeral head AVN. The incidence of postoperative complications in the observation group was significantly lower than the control group (P < 0.05), there was a significant difference between the two groups. Conclusions For Neer three‐ or four‐part PHF in the elderly patients, PHILOS fixation with fibular allograft shows satisfactory short‐term results with respect to humeral head support and maintenance of reduction, and may reduce the incidence of complications associated with fixation using a PHILOS alone.
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Affiliation(s)
- Lei Zhao
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi-Min Qi
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lei Yang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Gang-Rui Wang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Sheng-Nai Zheng
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qiang Wang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Bin Liang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chun-Zhi Jiang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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19
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Shen P, Zhu Y, Zhu L, Li X, Xu Y. Effects of medial support screws on locking plating of proximal humerus fractures in elderly patients: a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:560. [PMID: 31807541 DOI: 10.21037/atm.2019.09.61] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to explore the effects of medial support screws (MSS) on the locking proximal humeral plate in elderly patients who suffered from proximal humeral fractures. Methods From December 2016 to December 2018, eighty-five elderly patients who suffered from proximal humeral fracture and received standard plate or locking plate with or without MSS were selected. The patients were allocated into 3 groups: Standard plate group (n=23), Locking plate without MSS group (n=34) and Locking plate with MSS group (n=28). Clinical data from all these 3 groups were collected and analyzed. Results These eighty-five elder patients (ranging 60-78 years) accomplished a follow-up with an average of 16.3 months. The outcome data showed that significant difference was found on the Constant score, humeral internal rotation angle and humeral height ratio (all the P<0.05) among 3 groups, and a highest Constant score and a lowest humeral internal rotation angle and humeral height ratio loss was revealed in Locking platelet with MSS group. Furthermore, the lowest incidence of post-operation complication events (7.1%, P=0.051) and an evident reduction of secondary surgery incidence (P=0.021) was also presented in Locking plate with MSS among these 3 groups. Conclusions The medial support screws in the locking proximal humeral plate in treating proximal humeral fractures could reduce humerus restoration loss and humeral internal rotation angle.
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Affiliation(s)
- Pengcheng Shen
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou 215006, China.,Department of Orthopaedics, The Ninth People's Hospital of Suzhou City, Suzhou 215200, China
| | - Yu Zhu
- Department of Orthopaedics, Suzhou Hospital of Traditional Chinese Medicine, Suzhou 215100, China
| | - Lifan Zhu
- Department of Orthopaedics, The Ninth People's Hospital of Suzhou City, Suzhou 215200, China
| | - Xiaolin Li
- Department of Orthopaedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200233, China
| | - Yaozeng Xu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
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20
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Tilton M, Armstrong A, Sanville J, Chin M, Hast MW, Lewis GS, Manogharan GP. Biomechanical Testing of Additive Manufactured Proximal Humerus Fracture Fixation Plates. Ann Biomed Eng 2019; 48:463-476. [PMID: 31555983 DOI: 10.1007/s10439-019-02365-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/12/2019] [Indexed: 01/24/2023]
Abstract
Achieving satisfactory fracture fixation in osteoporotic patients with unstable proximal humerus fractures remains a major clinical challenge. Varus collapse is one of the more prominent complications that may lead to screw cutout. This aim of this study was to compare the fixation provided by conventional locking plates with novel design concepts that are only feasible through additive manufacturing (AM) techniques. In addition to reversed engineered implants, two novel implant designs with integrated struts were included in the study to provide medial support to humeral head. The medial strut was either solid or included a porous lattice structure intended to promote bone ingrowth. Biomechanical tests were performed using low density synthetic bones with simulated 3-part comminuted fractures. Nondestructive torsion and compression were performed, followed by increasing cyclic loading. The relative displacements between the bone fragments were determined using a 3D motion capture system. The AM manufactured implants with medial strut showed significant reduction of varus displacement during the increasing cyclic loading when compared to conventional designs. AM reversed-engineered locking plates showed similar mechanical behavior to conventional plates with identical geometry. This study demonstrates the feasibility and potential of employing alternative design via AM for fixation of unstable comminuted proximal humerus fractures to reduce fragment displacement.
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Affiliation(s)
- Maryam Tilton
- Department of Mechanical Engineering, Pennsylvania State University, 232 Reber Bldg, University Park, PA, 16802, USA
| | - April Armstrong
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jennifer Sanville
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Chin
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael W Hast
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Guha P Manogharan
- Department of Mechanical Engineering, Pennsylvania State University, 232 Reber Bldg, University Park, PA, 16802, USA.
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21
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Cassidy JT, Coveney E, Molony D. "90/90" Plating of proximal humerus fracture-a technical note. J Orthop Surg Res 2019; 14:41. [PMID: 30744652 PMCID: PMC6371547 DOI: 10.1186/s13018-019-1083-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/31/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION While locking plates have markedly improved fixation of proximal humerus fractures, a cohort of fractures remains difficult to treat. This cohort has been identified as fractures with marked medial comminution and varus deformity. Loss of reduction and fixation failure are the most frequently reported complications for this cohort. We report the use of an orthogonal 1/3 tubular plate to augment the proximal humerus locking plate. METHODS The subject underwent osteosynthesis for a four-part proximal humerus fracture with medial comminution. Fixation was performed within 24 h of injury. Standard deltopectoral approach exposed the fracture. Sutures were sited to control the tuberosities and cuff. Initial reduction was held with a K-wire and augmented with a three-hole 1/3 tubular plate. Proximal humerus locking plate was sited in standard fashion including locked medial support screws. Reduction was confirmed both clinically and with intra-operative radiography. RESULTS The technique provided satisfactory results. At 6 months, the fracture had fully united with no loss of reduction. At 1 year, the patient had excellent range of motion. CONCLUSION The use of a 1/3 tubular plate to augment fixation of proximal humerus fractures with medial comminution may provide a simple, reproducible, and cost-effective method to decrease loss of reduction and subsequent malunion.
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Jabran A, Peach C, Zou Z, Ren L. Biomechanical comparison of screw-based zones of a spatial subchondral support plate for proximal humerus fractures. Proc Inst Mech Eng H 2019; 233:372-382. [PMID: 30700217 DOI: 10.1177/0954411919827984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ali Jabran
- 1 School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK
| | - Chris Peach
- 1 School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK.,2 Department of Shoulder and Elbow Surgery, University Hospital of South Manchester, Manchester, UK
| | - Zhenmin Zou
- 1 School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK
| | - Lei Ren
- 1 School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK
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Theopold J, Schleifenbaum S, Müller M, Werner M, Hammer N, Josten C, Hepp P. Biomechanical evaluation of hybrid double plate osteosynthesis using a locking plate and an inverted third tubular plate for the treatment of proximal humeral fractures. PLoS One 2018; 13:e0206349. [PMID: 30372476 PMCID: PMC6205804 DOI: 10.1371/journal.pone.0206349] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 10/11/2018] [Indexed: 01/31/2023] Open
Abstract
Background Treating proximal humerus fractures can be challenging because of large metaphyseal defects that conceal anatomical landmarks. In such cases, medial cortical support with, for example, calcar screws, is mandatory. Nevertheless, varus dislocations and implant failures in patients with impaired bone quality persist. Thus, the need for effective treatment of these patients exists. Hybrid double plate osteosynthesis was introduced as an alternative, yielding similar results as calcar screws. However, a biomechanical comparison of the stability of these two techniques is pending. Methods Cadaveric humeral specimens were treated with plate osteosynthesis and calcar screws (group 1, n = 9) or hybrid double plate osteosynthesis (group 2, n = 9) using a proximal humerus fracture model with a two-part fracture. Displacement, stiffness, failure mode, and ultimate load were examined biomechanically in a cyclic compressive-loading scenario. Results Although the hybrid double plate osteosynthesis (group 2) tended to confer higher stiffnesses than the medial support screws at higher cycles (group 1), this trend was below the level of significance. The displacement revealed non-significantly lower values for group 1 as compared with group 2 for cycles 50 and 2000, but at 5000 cycles, group 2 offered non-significantly lower displacement values than group 1. The ultimate load tended to be non-significantly higher in the hybrid double plate osteosynthesis group (group 2: 1342±369 N, group 1: 855±408 N). Both groups yielded similar failure rates, with the majority of failures in group 2 being gap closures (n = 8), whereas those in group 1 being plate dislocations (n = 4). Conclusions The use of an additive plate osteosynthesis in the region of the bicipital groove may be a potential alternative to the previously-established method of using calcar screws. The biomechanical data obtained in this study suggests that hybrid double plate osteosynthesis is as rigid and robust as calcar screws.
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Affiliation(s)
- Jan Theopold
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- * E-mail:
| | - Stefan Schleifenbaum
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
- ZESBO–Zentrum zur Erforschung der Stuetz- und Bewegungsorgane, Leipzig, Germany
| | - Mirijam Müller
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Michael Werner
- Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany
| | - Niels Hammer
- Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Christoph Josten
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Pierre Hepp
- Department of Orthopedic, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
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Lindsay C, Hasty E, Carpenter D, Weinhold P, Ostrum RF. Proximal Humeral Locking Plates: A Cadaveric Study of 5 Versus 7 Metaphyseal Locking Screws. Orthopedics 2018; 41:306-311. [PMID: 30168835 DOI: 10.3928/01477447-20180828-04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/18/2018] [Indexed: 02/03/2023]
Abstract
The most common operative treatment of proximal humerus fractures is internal fixation with fixed-angle locking plates. Although this surgical technique has been refined, a significant failure rate remains. This study aimed to determine whether the number of locking screws in the humeral head affects the biomechanical strength and stability of the construct in bone from elderly individuals. Ten pairs of embalmed cadaveric humeri were osteotomized in a gap model and fixed with periarticular locking plates placed in the standard position. Five or 7 proximal locking screws were inserted. Mechanical testing was performed, and cyclic displacements and maximum force to failure were recorded. No significant difference was found between 5 and 7 locking screws in mean cyclic displacement on the medial (1.09 mm vs 1.12 mm, P=.834) or posterior (0.45 mm vs 0.42 mm, P=.791) sides of the fracture model. On testing to failure, 7 and 5 screws showed similar stiffness (336 N/mm vs 292 N/mm, P=.176), force at ultimate load (745 N vs 662 N, P=.309), and displacement at ultimate load (5.90 mm vs 4.36 mm, P=.080). All samples failed at diaphyseal fixation, and no screw cutout or varus collapse was observed. Results from this study suggest that there is no significant difference between 5 and 7 metaphyseal locking screws for stiffness of fixation of proximal humeral fractures in elderly patients. With the inherent possibility of screw penetration of the humeral head, fewer screws may lead to fewer complications. [Orthopedics. 2018; 41(5):306-311.].
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Zeng LQ, Zeng LL, Jiang YW, Wei HF, Zhang W, Chen YF. Influence of Medial Support Screws on the Maintenance of Fracture Reduction after Locked Plating of Proximal Humerus Fractures. Chin Med J (Engl) 2018; 131:1827-1833. [PMID: 30058580 PMCID: PMC6071468 DOI: 10.4103/0366-6999.237396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Technical aspects of the correct placement of medial support locking screws in the locking plate for proximal humerus fractures remain incompletely understood. This study was to evaluate the clinical relationship between the number of medial support screws and the maintenance of fracture reduction after locked plating of proximal humerus fractures. Methods We retrospectively evaluated 181 patients who had been surgically treated for proximal humeral fractures (PHFs) with a locking plate between September 2007 and June 2013. All cases were then subdivided into one of four groups as follows: 75 patients in the medial cortical support (MCS) group, 26 patients in the medial multiscrew support (MMSS) group, 29 patients in the medial single screw support (MSSS) group, and 51 patients in the no medial support (NMS) group. Clinical and radiographic evaluations included the Constant-Murley score (CM), visual analogue scale (VAS), complications, and revision surgeries. The neck-shaft angle (NSA) was measured in a true anteroposterior radiograph immediately postoperation and at final follow-up. One-way analysis of variance or Kruskal-Wallis test was used for statistical analysis of measurement data, and Chi-square test or Fisher's exact test was used for categorical data. Results The mean postoperative NSAs were 133.46° ± 6.01°, 132.39° ± 7.77°, 135.17° ± 10.15°, and 132.41° ± 7.16° in the MCS, MMSS, MSSS, and NMS groups, respectively, and no significant differences were found (F = 1.02, P = 0.387). In the final follow-up, the NSAs were 132.79° ± 6.02°, 130.19° ± 9.25°, 131.28° ± 12.85°, and 127.35° ± 8.50° in the MCS, MMSS, MSSS, and NMS groups, respectively (F = 4.40, P = 0.008). There were marked differences in the NSA at the final follow-up between the MCS and NMS groups (P = 0.004). The median (interquartile range [IQR]) NSA losses were 0.0° (0.0-1.0)°, 1.3° (0.0-3.1)°, 1.5° (1.0-5.2)°, and 4.0° (1.2-7.1)° in the MCS, MMSS, MSSS, and NMS groups, respectively (H = 60.66, P < 0.001). There were marked differences in NSA loss between the MCS and the other three groups (MCS vs. MMSS, Z = 3.16, P = 0.002; MCS vs. MSSS, Z = 4.78, P < 0.001; and MCS vs. NMS, Z = 7.34, P < 0.001). There was also significantly less NSA loss observed in the MMSS group compared to the NMS group (Z = -3.16, P = 0.002). However, there were no significant differences between the MMSS and MSSS groups (Z = -1.65, P = 0.225) or the MSSS and NMS groups (Z = -1.21, P = 0.099). The average CM scores were 81.35 ± 9.79, 78.04 ± 8.97, 72.76 ± 10.98, and 67.33 ± 12.31 points in the MCS, MMSS, MSSS, and NMS groups, respectively (F = 18.68, P < 0.001). The rates of excellent and good CM scores were 86.67%, 80.77%, 65.52%, and 43.14% in the MCS, MMSS, MSSS, and NMS groups, respectively (χ2 = 29.25, P < 0.001). The median (IQR) VAS scores were 1 (0-2), 1 (0-2), 2 (1-3), and 3 (1-5) points in the MCS, MMSS, MSSS, and NMS groups, respectively (H = 27.80, P < 0.001). Functional recovery was markedly better and VAS values were lower in the MCS and MMSS groups (for CM scores: MCS vs. MSSS, P < 0.001; MCS vs. NMS, P < 0.001; MMSS vs. MSSS, P = 0.031; and MMSS vs. NMS, P < 0.001 and for VAS values: MCS vs. MSSS, Z = 3.31, P = 0.001; MCS vs. NMS, Z = 4.64, P < 0.001; MMSS vs. MSSS, Z = -2.09, P = 0.037; and MMSS vs. NMS, Z = -3.16, P = 0.003). Conclusions Medial support screws might help enhance mechanical stability and maintain fracture reduction when used to treat PHFs with medial metaphyseal comminution or malreduction.
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Affiliation(s)
- Lang-Qing Zeng
- Department of Orthopaedics, Zhuhai City People's Hospital, Jinan University Affiliated Zhuhai Hospital, Jinan University, Zhuhai, Guangdong 519000, China
| | - Lu-Lu Zeng
- Department of Anesthesiology, Zhuhai City People's Hospital, Jinan University Affiliated Zhuhai Hospital, Jinan University, Zhuhai, Guangdong 519000, China
| | - Yu-Wen Jiang
- Department of Orthopaedics, Zhuhai City People's Hospital, Jinan University Affiliated Zhuhai Hospital, Jinan University, Zhuhai, Guangdong 519000, China
| | - Hai-Feng Wei
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Wen Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Yun-Feng Chen
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China
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Jabran A, Peach C, Zou Z, Ren L. Biomechanical comparison of screw-based zoning of PHILOS and Fx proximal humerus plates. BMC Musculoskelet Disord 2018; 19:253. [PMID: 30045716 PMCID: PMC6060456 DOI: 10.1186/s12891-018-2185-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/11/2018] [Indexed: 11/20/2022] Open
Abstract
Background Treatment of proximal humerus fractures with locking plates is associated with complications. We aimed to compare the biomechanical effects of removing screws and blade of a fixed angle locking plate and hybrid blade plate, on a two-part fracture model. Methods Forty-five synthetic humeri were divided into nine groups where four were implanted with a hybrid blade plate and the remaining with locking plate, to treat a two-part surgical neck fracture. Plates’ head screws and blades were divided into zones based on their distance from fracture site. Two groups acted as a control for each plate and the remaining seven had either a vacant zone or blade swapped with screws. For elastic cantilever bending, humeral head was fixed and the shaft was displaced 5 mm in extension, flexion, valgus and varus direction. Specimens were further loaded in varus direction to investigate their plastic behaviour. Results In both plates, removal of inferomedial screws or blade led to a significantly larger drop in varus construct stiffness than other zones. In blade plate, insertion of screws in place of blade significantly increased the mean extension, flexion valgus and varus bending stiffness (24.458%/16.623%/19.493%/14.137%). In locking plate, removal of screw zones proximal to the inferomedial screws reduced extension and flexion bending stiffness by 26–33%. Conclusions Although medial support improved varus stability, two inferomedial screws were more effective than blade. Proximal screws are important for extension and flexion. Mechanical consequences of screw removal should be considered when deciding the number and choice of screws and blade in clinic. Electronic supplementary material The online version of this article (10.1186/s12891-018-2185-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ali Jabran
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK
| | - Chris Peach
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK.,Department of Shoulder and Elbow Surgery, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester, M23 9LT, UK
| | - Zhenmin Zou
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK
| | - Lei Ren
- School of Mechanical, Aerospace and Civil Engineering, University of Manchester, Sackville Street, Manchester, M13 9PL, UK.
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Biomechanical analysis of plate systems for proximal humerus fractures: a systematic literature review. Biomed Eng Online 2018; 17:47. [PMID: 29703261 PMCID: PMC5923007 DOI: 10.1186/s12938-018-0479-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 04/18/2018] [Indexed: 02/04/2023] Open
Abstract
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.
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Mehta S, Chin M, Sanville J, Namdari S, Hast MW. Calcar screw position in proximal humerus fracture fixation: Don't miss high! Injury 2018; 49:624-629. [PMID: 29452734 PMCID: PMC7413303 DOI: 10.1016/j.injury.2018.02.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 02/06/2018] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Samir Mehta
- Biedermann Lab for Orthopaedic Research, University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, PA, United States
| | - Matthew Chin
- Biedermann Lab for Orthopaedic Research, University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, PA, United States
| | - Jennifer Sanville
- Biedermann Lab for Orthopaedic Research, University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, PA, United States
| | - Surena Namdari
- Rothman Institute, Thomas Jefferson University, Department of Orthopaedic Surgery, Philadelphia, PA, United States
| | - Michael W. Hast
- Biedermann Lab for Orthopaedic Research, University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, PA, United States,Corresponding author at: Biedermann Laboratory for Orthopaedic Research, University of Pennsylvania, 3737 Market Street, Suite 1050,10th Floor, Philadelphia, PA 19104, United States. (M.W. Hast)
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Qiang M, Jia X, Chen Y, Zhang K, Li H, Jiang Y, Zhang Y. Assessment of Screw Length of Proximal Humerus Internal Locking System (PHILOS) Plate for Proximal Humeral Fractures Using Three-Dimensional Computed Tomography Scan. Med Sci Monit 2018; 24:1158-1165. [PMID: 29478073 PMCID: PMC5836538 DOI: 10.12659/msm.906355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Screw perforation and varus collapse are common complications of treatment with a PHILOS (proximal humerus internal locking system) plate for proximal humerus fractures, which are associated with improper screw length selection and lack of medial column support. The purposes of this study were: (1) to measure the proper length of periarticular screws of the PHILOS plate in the humeral head, and (2) to determine what factors influence the screw length and implantation of the inferomedial support screw. Material/Methods Computed tomography (CT) images of the normal proximal humerus in 134 cases were retrospectively reviewed. The length of periarticular screws was measured using three-dimensional (3D) techniques. Intraobserver and interobserver reliability of measurement were evaluated using intraclass correlation coefficients (ICCs). Sex and body height influences on screw length and implantation of the inferomedial screw were analyzed. Results All measurements had excellent agreement (ICC>0.75). The screw length and implantation rate of the inferomedial screw were greater in males than in females. Positive correlations were observed between body height and screw length and implantation of the inferomedial screw (all P<0.001). Conclusions The screws were longer and the implantation rate was higher for inferomedial screws in males than in females, and were positively correlated with body height. Our data can be used as a reference for surgeons to reduce the number of times screws are changed intraoperatively and to reduce operation duration and minimize use of intraoperative fluoroscopy for proximal humerus fractures treated with the PHILOS plate.
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Affiliation(s)
- Minfei Qiang
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Xiaoyang Jia
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yanxi Chen
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Kun Zhang
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Haobo Li
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yuchen Jiang
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Yijie Zhang
- Department of Orthopedic Trauma, East Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
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Butler MA, Chauhan A, Merrell GA, Greenberg JA. Establishing the appropriate position of proximal humerus locking plates: a cadaveric study of five plating systems and their anatomic reference measurements. Shoulder Elbow 2018; 10:40-44. [PMID: 29276536 PMCID: PMC5734525 DOI: 10.1177/1758573217704816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 02/08/2017] [Accepted: 03/10/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The present study aimed to determine anatomic references for the placement of five proximal humerus locking plates. METHODS Five proximal humerus locking-plate systems were placed on six human shoulder cadavers. Plates were positioned by fluoroscopic confirmation so that the inferior oblique screw was within 5 mm of the inferomedial cortex. Plate position was measured using the superior border of the pectoralis major tendon (PMT) to the bottom of the first slotted or nonlocking hole and top of the plate to the top of the greater tuberosity. The distance from the PMT insertion to the top of the humeral head was measured as a control. RESULTS There was consistency within each plating system for both the distance from the PMT insertion to the first hole and the top of the plate to the greater tuberosity: Synthes first-generation [mean (SD) 13.7 mm (3.1 mm); 10 mm (1.3) mm], Synthes second-generation [28.2 mm (2.2 mm); 18.5 mm (2.7 mm)], Biomet OptiLock® [25.5 mm (2.7 mm); 18.7 mm (2 mm)], Stryker AxSOS® [5 mm (2.8 mm); 12.3 mm (3.3 mm)] and Acumed Polarus® [9.5 mm (1.8 mm); 14.8 mm (1.6 mm)]. CONCLUSIONS The present study provides measurements that improve the accuracy of plate positioning for five plating systems.
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Affiliation(s)
| | - Aakash Chauhan
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Jeffrey A Greenberg
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA,Jeffrey A Greenberg, Indiana Hand to Shoulder Center, 8501 Harcourt Road, Indianapolis, IN 46260, USA.
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Rollo G, Rotini R, Pichierri P, Giaracuni M, Stasi A, Macchiarola L, Bisaccia M, Meccariello L. Grafting and fixation of proximal humeral aseptic non union: a prospective case series. ACTA ACUST UNITED AC 2017; 14:298-304. [PMID: 29354157 DOI: 10.11138/ccmbm/2017.14.3.298] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Fractures of the proximal part of the humerus represent almost 4-5% of all fractures. The rate of non union is estimated to be 1.1 to 10%. Non union, displacement, and fixation failure can be hazardous complications for these injuries. The purpose of our study was to evaluate the outcomes of plate and bone strut allograft with bone chips grafting augmentation in the management of proximal humeral aseptic non union. Methods We treated 16 aseptic non union proximal humeral fractures by the medial humeral shaft bone strut allograft and lateral plate and screws with bone chips grafting. The patients' ages were between 55 and 70 years. The chosen criteria to evaluate the group during the clinical and radiological follow-up were the quality of life measured by The Short Form (12) Health Survey (SF-12), shoulder function and related quality of life measured by the Constant Shoulder Score (CSS) compared with healthy side, bone healing measured by X-rays, and postoperative complications. The follow-up was perfor med with clinical and radiographic controls at 1, 3, 6 and 12 months. Surgical time and international units of red blood cells transfused were also calculated. The evaluation endpoint was set at 12 months. Results The X-rays bone healing occurred in our group on average of 126.4 days after surgery. The surgical time and blood loss were consistent with standard surgical procedures. The quality of life and functional recovery were excellent after plate and bone strut allograft. Conclusions Surgical techniques that increase mechanical stability, while incorporating bone biology, are effective aids for treating problematic fractural patterns.
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Affiliation(s)
- Giuseppe Rollo
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Roberto Rotini
- Shoulder and Elbow Unit, "Rizzoli" Orthopedic Institute, Bologna, Italy
| | - Paolo Pichierri
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Marco Giaracuni
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Alessandro Stasi
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Luca Macchiarola
- Shoulder and Elbow Unit, "Rizzoli" Orthopedic Institute, Bologna, Italy
| | - Michele Bisaccia
- Division of Orthopedics and Trauma Surgery, University of Perugia, "S. Maria della Misericordia" Hospital, Perugia, Italy
| | - Luigi Meccariello
- UOC Orthopedics and Traumatology, "Vito Fazzi" Hospital, Lecce, Italy
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Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res 2017; 12:137. [PMID: 28946902 PMCID: PMC5613450 DOI: 10.1186/s13018-017-0639-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.
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Affiliation(s)
- Christoph J Laux
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Florian Grubhofer
- Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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The Applications of Finite Element Analysis in Proximal Humeral Fractures. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017; 2017:4879836. [PMID: 29081829 PMCID: PMC5610852 DOI: 10.1155/2017/4879836] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/06/2017] [Indexed: 12/18/2022]
Abstract
Proximal humeral fractures are common and most challenging, due to the complexity of the glenohumeral joint, especially in the geriatric population with impacted fractures, that the development of implants continues because currently the problems with their fixation are not solved. Pre-, intra-, and postoperative assessments are crucial in management of those patients. Finite element analysis, as one of the valuable tools, has been implemented as an effective and noninvasive method to analyze proximal humeral fractures, providing solid evidence for management of troublesome patients. However, no review article about the applications and effects of finite element analysis in assessing proximal humeral fractures has been reported yet. This review article summarized the applications, contribution, and clinical significance of finite element analysis in assessing proximal humeral fractures. Furthermore, the limitations of finite element analysis, the difficulties of more realistic simulation, and the validation and also the creation of validated FE models were discussed. We concluded that although some advancements in proximal humeral fractures researches have been made by using finite element analysis, utility of this powerful tool for routine clinical management and adequate simulation requires more state-of-the-art studies to provide evidence and bases.
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He Y, Zhang Y, Wang Y, Zhou D, Wang F. Biomechanical evaluation of a novel dualplate fixation method for proximal humeral fractures without medial support. J Orthop Surg Res 2017; 12:72. [PMID: 28499398 PMCID: PMC5429529 DOI: 10.1186/s13018-017-0573-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 04/26/2017] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Yu He
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Beijing, 100010, China
| | - Yaoshen Zhang
- Department of Orthopedics, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti Nanlu, Beijing, 100020, China
| | - Yan Wang
- Department of Medical Laboratory Diagnosis Center, Jinan Central Hospital, No. 105 Jiefang Road, Ji'nan, 250014, Shandong, China
| | - Dongsheng Zhou
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Ji'nan, 250021, Shandong, China
| | - Fu Wang
- Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, No. 324 Jingwu Road, Ji'nan, 250021, Shandong, China.
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Hsiao CK, Tsai YJ, Yen CY, Lee CH, Yang TY, Tu YK. Intramedullary cortical bone strut improves the cyclic stability of osteoporotic proximal humeral fractures. BMC Musculoskelet Disord 2017; 18:64. [PMID: 28153021 PMCID: PMC5290624 DOI: 10.1186/s12891-017-1421-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 01/20/2017] [Indexed: 11/22/2022] Open
Abstract
Background Proximal humeral fractures treated with locking plate can fail due to varus collapse, especially in osteoporotic bone with medial cortex comminution. The use of an intramedullary strut together with locking plate fixation may strengthen fixation and provide additional medial support to prevent the varus malalignment. This study biomechanically investigates the influence of an intramedullary cortical bone strut on the cyclic stability of proximal humeral fractures stabilized by locking plate fixation in a cadaver model. Methods Ten cadaveric humeri were divided into two groups statistically matched for bone density. Each specimen was osteotomized with 10 mm gap at the surgical neck. The non-augmented group stabilized with locking plate alone; in the augmented group, a locking plate was used combined with an intramedullary cortical bone strut. The strut was retrograded into the subchondral bone, and three humeral head screws were inserted into the strut to form a plate-screw-strut mechanism. The cyclic axial load was performed to 450 N for 6000 cycles and then loaded to failure. Construct stiffness, cyclic loading behavior and failure strength were analyzed to identify differences between groups. Results The augmented constructs were significantly stiffer than the non-augmented constructs during cycling. On average, the maximum displacements at 6000 cycles for non-augmented and augmented groups were 3.10 ± 0.75 mm and 1.7 ± 0.65 mm (p = 0.01), respectively. The mean peak-to-peak (inter cycle) displacement at 6000 cycles was about 2 times lower for the augmented group (1.36 ± 0.68 mm vs. 2.86 ± 0.51 mm). All specimens showed varus collapse combined with loss of screw fixation of the humeral head. The failure load of the augmented group was increased by 2.0 (SD = 0.41) times compared with the non-augmented group (p < 0.001). Conclusions The stability and strength of the locking plate augmented with an intramedullary strut were significantly increased. For bone with poor quality, the subsidence of the locked screws led larger displacement, decreased the stability of the constructs, however, the plate-screw-strut mechanism provided more rigidity to stabilize the fixation. This study emphasized the importance of intramedullary support for the proximal humeral fractures fixed with a locked plate under cyclic loading, especially in bone with poor quality. This work is based on the results of cadaver model, further in vivo analysis is necessary to determine if the clinical results can be extrapolated from this data.
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Affiliation(s)
- Chih-Kun Hsiao
- Department of Medical Research, E-Da Hospital, No. 1 E-Da Rd, Yuan-Chau District, Kaohsiung, Taiwan
| | - Yi-Jung Tsai
- Department of Medical Research, E-Da Hospital, No. 1 E-Da Rd, Yuan-Chau District, Kaohsiung, Taiwan
| | - Cheng-Yo Yen
- Department of Orthopedics, E-Da Hospital, No. 1 E-Da Rd, Yuan-Chau District, Kaohsiung, Taiwan
| | - Cheng-Hung Lee
- Department of Orthopedics, Veterans General Hospital, No.1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan
| | - Teng-Yao Yang
- Department of Orthopedics, E-Da Hospital, No. 1 E-Da Rd, Yuan-Chau District, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, No. 1 E-Da Rd, Yuan-Chau District, Kaohsiung, Taiwan.
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Analysis of four-fragment fractures of the proximal humerus: the interest of 2D and 3D imagery and inter- and intra-observer reproducibility. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:295-299. [PMID: 28120098 DOI: 10.1007/s00590-017-1911-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
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Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:17-22. [PMID: 27866913 PMCID: PMC6197619 DOI: 10.1016/j.aott.2016.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/31/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of the present study was to evaluate results, including clinical and radiological outcomes and number of complications, following minimally invasive plate osteosynthesis (MIPO) of proximal humerus fractures, using the PHILOS® proximal humerus internal locking system (Synthes Holding AG, Solothurn, Switzerland). METHODS Retrospectively evaluated were 31 patients treated with MIPO (12 male, 19 female; average age: 58.4 years). Four patients had 2-part fractures, 14 patients had 3-part fractures, and 13 patients had 4-part fractures, according to Neer classification. Healing, complications, and head-shaft angle (HSA) were radiographically evaluated. Clinical outcomes were assessed at 1-year follow-up with Constant score. RESULTS Average Constant scores for fractured and normal shoulders were 73.2 ± 10.9 and 84.8 ± 5.1, respectively. Varus progression, fracture type, and age had no significant effect on functional outcome. Average postoperative and follow-up HSA's were 130.80 ± 7.70 and 128.80 ± 10.00, respectively. Significant varus progression was observed during follow-up (p = 0.01). Varus progression was more prominent in patients with postoperative HSA < 130° (p < 0.001). Inferomedial calcar screw usage, fracture type, and age had no significant effect on varus progression. Complications included 2 implant failures, 1 case of avascular necrosis (AVN), 1 primary screw cut-out, 1 axillary nerve injury, and 1 radial nerve injury (22.6% overall). CONCLUSION MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. Reduction may be difficult, resulting in varus progression. Another disadvantage is risk of axillary nerve injury. Careful surgical technique and correct implant selection is important in the prevention of nerve injury. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Katthagen JC, Schwarze M, Warnhoff M, Voigt C, Hurschler C, Lill H. Influence of plate material and screw design on stiffness and ultimate load of locked plating in osteoporotic proximal humeral fractures. Injury 2016; 47:617-24. [PMID: 26804939 DOI: 10.1016/j.injury.2016.01.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 12/18/2015] [Accepted: 01/09/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The main purpose was to compare the biomechanical properties of a carbon-fibre reinforced polyetheretherketone (CF-PEEK) composite locking plate with pre-existing data of a titanium-alloy plate when used for fixation of an unstable 2-part fracture of the surgical neck of the humerus. The secondary purpose was to compare the mechanical behaviour of locking bolts and conventional locking cancellous screws. METHODS 7 pairs of fresh frozen human humeri were allocated to two equal groups. All specimens were fixed with the CF-PEEK plate. Cancellous screws (PEEK/screw) were compared to locking bolts (PEEK/bolt) for humeral head fixation. Stiffness, fracture gap deflection and ultimate load as well as load before screw perforation of the articular surface were assessed. Results were compared between groups and with pre-existing biomechanical data of a titanium-alloy plate. RESULTS The CF-PEEK plate featured significantly lower stiffness compared to the titanium-alloy plate (P<0.001). In ultimate load testing, 6 out of 14 CF-PEEK plates failed due to irreversible deformation and cracking. No significant difference was observed between results of groups PEEK/screw and PEEK/bolt (P>0.05). DISCUSSION The CF-PEEK plate has more elastic properties and significantly increases movement at the fracture site of an unstable proximal humeral fracture model compared to the commonly used titanium-alloy plate. The screw design however does neither affect the constructs primary mechanical behaviour in the constellation tested nor the load before screw perforation.
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Affiliation(s)
- Jan Christoph Katthagen
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany.
| | - Michael Schwarze
- Laboratory of Biomechanics and Biomaterials, Medizinische Hochschule Hannover (MHH), Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - Mara Warnhoff
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - Christine Voigt
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - Christof Hurschler
- Laboratory of Biomechanics and Biomaterials, Medizinische Hochschule Hannover (MHH), Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - Helmut Lill
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
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Panchal K, Jeong JJ, Park SE, Kim WY, Min HK, Kim JY, Ji JH. Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft. INTERNATIONAL ORTHOPAEDICS 2015; 40:569-77. [PMID: 26257277 DOI: 10.1007/s00264-015-2950-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 07/24/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the clinical and radiological outcomes of unstable proximal humeral fractures (PHFs) treated with a locking plate and fibular strut allograft. METHODS This study included 36 patients [7 men, 29 women; mean age, 68 years (range, 22-94 years)] with unstable PHFs with medial column disruption. All patients were treated with open reduction and internal fixation using a locking plate and fibular strut allograft. Post-operative assessment included clinical outcomes, shoulder range of motion, radiographic examination, and any complications. Post-operative radiological assessment including the humerus neck-shaft angle (NSA) and the humeral head height was performed. RESULTS At the mean two year follow-up visit, the mean American Shoulder and Elbow Society (ASES) and University of California, Los Angeles (UCLA) scores were 77 and 28, respectively. According to the UCLA rating scale, the result was excellent in six, good in 20, fair in six, and poor in four cases. According to the Paavolainen method, 31 patients had good results with an NSA of 130 ± 10°; three patients showed fair results with an NSA of 100-120°, and two patients experienced a poor result with an NSA of <100°. When calculating the humeral head height, the mean loss of reduction was measured as 1.6 mm (from 10.8 or 9.2 mm). Varus collapse and avascular necrosis of the humeral head was noted in two patients for each condition. CONCLUSIONS For unstable proximal humerus fractures, particularly in elderly patients with severe osteoporosis or in younger patients with a four-part fracture, locking plate fixation with a fibular strut allograft provided rigid medial support and showed satisfactory clinical and radiological outcomes.
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Affiliation(s)
- Karnav Panchal
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea
| | - Jae-Jung Jeong
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea
| | - Sang-Eun Park
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea.
| | - Weon-Yoo Kim
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea
| | - Hyung-Ki Min
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea
| | - Ju-Yeong Kim
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea
| | - Jong-Hun Ji
- Department of Orthopaedic Surgery, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daeheung-ro 64, Jung-gu, Daejeon, 301-723, Republic of Korea.
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Katthagen JC, Schwarze M, Bauer L, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H. Is there any advantage in placing an additional calcar screw in locked nailing of proximal humeral fractures? Orthop Traumatol Surg Res 2015; 101:431-5. [PMID: 25922285 DOI: 10.1016/j.otsr.2015.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 09/25/2014] [Accepted: 01/06/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the biomechanical effect of an additional unlocked calcar screw compared to a standard setting with three proximal humeral head screws alone for fixation of an unstable 2-part fracture of the surgical neck. HYPOTHESIS The additional calcar screw improves stiffness and failure load. METHODS Fourteen fresh frozen humeri were randomized into two equal sized groups. An unstable 2-part fracture of the surgical neck was simulated and all specimens were fixed with the MultiLoc(®)-nail. Group I represented a basic screw setup, with three locked head screws and two unlocked shaft screws. Group II was identical with a supplemental unlocked calcar screw (CS). Stiffness tests were performed in torsional loading, as well as in axial and in 20° abduction/20° adduction modes. Subsequently cyclic loading and load-to-failure tests were performed. Resulting stiffness, displacement under cyclic load and ultimate load were compared between groups using the t-test for independent variables (α=0.05). RESULTS No significant differences were observed between the groups in any of the biomechanical parameters. Backing out of the CS was observed in three cases. DISCUSSION The use of an additional unlocked calcar screw does not provide mechanical benefit in locked nailing of an unstable 2-part fracture of the surgical neck.
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Affiliation(s)
- J C Katthagen
- Department of Reconstructive and Trauma Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany.
| | - M Schwarze
- Laboratory of Biomechanics and Biomaterials, Medizinische Hochschule Hannover (MHH), Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - L Bauer
- Department of Reconstructive and Trauma Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - J Meyer-Kobbe
- Department of Reconstructive and Trauma Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - C Voigt
- Department of Reconstructive and Trauma Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - C Hurschler
- Laboratory of Biomechanics and Biomaterials, Medizinische Hochschule Hannover (MHH), Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - H Lill
- Department of Reconstructive and Trauma Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
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Medial calcar support and radiographic outcomes of plate fixation for proximal humeral fractures. BIOMED RESEARCH INTERNATIONAL 2015; 2015:170283. [PMID: 25692132 PMCID: PMC4322828 DOI: 10.1155/2015/170283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 11/17/2022]
Abstract
Plate fixation remains one of the most popular surgical procedures for treating proximal humeral fractures (PHFx); however, substantial rates of complications have been reported in the literature. The objectives of the study were to examine how medial calcar support (MCS) affects the radiographic outcomes and to determine the prognostic factors predicting treatment failure. We performed a retrospective cohort study of 89 adult patients who had PHFx and were treated with plate fixation at our institution in 2007–2011. The enrolled patients were separated into two groups according to disruption of medial calcar. Our results revealed an increased rate of poor radiographic outcomes in patients with disrupted medial calcar. Osteonecrosis of the humeral head and redisplacement were the two radiographic outcomes which had a positive causality with disruption of medial calcar (P = 0.008 and 0.050, resp.). Deficient medial calcar, inadequate reduction, diabetes mellitus, chronic kidney disease, and chronic liver disease were all significant predictors for the development of osteonecrosis in patients after PHFx surgery. Inadequate reduction was also a predictor for redisplacement. We confirmed that the restoration of medial calcar as well as comorbid conditions plays key roles in treatment of patients having PHFx with disrupted medial calcar.
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Sohn HS, Shin SJ. Minimally invasive plate osteosynthesis for proximal humeral fractures: clinical and radiologic outcomes according to fracture type. J Shoulder Elbow Surg 2014; 23:1334-40. [PMID: 24618198 DOI: 10.1016/j.jse.2013.12.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 12/10/2013] [Accepted: 12/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study evaluated the clinical and radiologic outcomes, according to fracture type, of proximal humeral fractures treated by the minimally invasive plate osteosynthesis (MIPO) technique. MATERIALS AND METHODS Of 85 patients with proximal humeral fractures who were treated by the MIPO technique, 62 were evaluated: 27 with 2-part fractures, 24 with 3-part fractures, and 11 with 4-part fractures. An additional inferomedial screw or fibular allograft was used when severe medial cortical comminution was found in the proximal humerus. Clinical and radiographic outcomes were evaluated during the follow-up of 37 months. RESULTS There was a significant difference in the Constant scores of patients with 4-part fractures compared with those with 3-part fractures (P = .039). The neck-shaft angle in 4-part fractures (121° ± 3°) at final follow-up was significantly lower compared with other fracture types (2-part: 129° ± 9°, P = .036; 3-part: 129° ± 2°, P = .031). Complication rates (72.7%) of 4-part fractures were significantly higher than with other fracture types (2-part, 7.4%; 3-part, 20.8%; P = .001). Sixteen fractures were fixed with an additional inferomedial screw, and 3 patients had insertion of a fibular allograft. CONCLUSION Satisfactory clinical and radiologic outcomes were obtained by the MIPO technique in proximal humeral fractures. In addition, medial cortical support can be performed with an inferomedial screw or fibular allograft in the MIPO technique. However, the MIPO technique for 4-part fractures showed relatively inferior outcomes compared with 2- and 3-part fractures. Conversion to open plating is also considered if adequate reduction, that is, a neck-shaft angle >120°, is not able to be obtained in the MIPO technique for 4-part fractures of the proximal humerus.
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Affiliation(s)
- Hoon-Sang Sohn
- Orthopaedic Surgery, National Medical Center, Seoul, South Korea
| | - Sang-Jin Shin
- Department of Orthopaedic Surgery, Ewha Womans University College of Medicine, Seoul, South Korea.
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Zhang W, Zeng L, Liu Y, Pan Y, Zhang W, Zhang C, Zeng B, Chen Y. The mechanical benefit of medial support screws in locking plating of proximal humerus fractures. PLoS One 2014; 9:e103297. [PMID: 25084520 PMCID: PMC4118867 DOI: 10.1371/journal.pone.0103297] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 06/28/2014] [Indexed: 11/26/2022] Open
Abstract
Background The purpose of this study was to evaluate the biomechanical advantages of medial support screws (MSSs) in the locking proximal humeral plate for treating proximal humerus fractures. Methods Thirty synthetic left humeri were randomly divided into 3 subgroups to establish two-part surgical neck fracture models of proximal humerus. All fractures were fixed with a locking proximal humerus plate. Group A was fixed with medial cortical support and no MSSs; Group B was fixed with 3 MSSs but without medial cortical support; Group C was fixed with neither medial cortical support nor MSSs. Axial compression, torsional stiffness, shear stiffness, and failure tests were performed. Results Constructs with medial support from cortical bone showed statistically higher axial and shear stiffness than other subgroups examined (P<0.0001). When the proximal humerus was not supported by medial cortical bone, locking plating with medial support screws exhibited higher axial and torsional stiffness than locking plating without medial support screws (P≤0.0207). Specimens with medial cortical bone failed primarily by fracture of the humeral shaft or humeral head. Specimens without medial cortical bone support failed primarily by significant plate bending at the fracture site followed by humeral head collapse or humeral head fracture. Conclusions Anatomic reduction with medial cortical support was the stiffest construct after a simulated two-part fracture. Significant biomechanical benefits of MSSs in locking plating of proximal humerus fractures were identified. The reconstruction of the medial column support for proximal humerus fractures helps to enhance mechanical stability of the humeral head and prevent implant failure.
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Affiliation(s)
- Wen Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Langqing Zeng
- Department of Orthopaedics, Zhuhai People's Hospital, Jinan University Affiliated Zhuhai Hospital, Guangdong, China
| | - Yanjie Liu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Pan
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Changqing Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bingfang Zeng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunfeng Chen
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Katthagen JC, Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H. Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures. Clin Biomech (Bristol, Avon) 2014; 29:735-41. [PMID: 24997810 DOI: 10.1016/j.clinbiomech.2014.06.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 06/11/2014] [Accepted: 06/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The objective of this study was to investigate the biomechanical effects of medial fracture gap augmentation in locked plating of an unstable 2-part proximal humeral fracture with calcar screws and insertion of a corticocancellous bone block. Furthermore the mechanical behavior of dynamic locking screws in the non-parallel arrangement of a proximal humeral plate was of interest. METHODS Thirty-two fresh frozen humeri were randomized in four equal groups. An unstable 2-part fracture was fixed by locked plating in all specimens. The basic screw setup was supplemented by additional calcar screws in one group. Humeral head screws were replaced by dynamic locking screws in a second group. The third group featured an additional corticocancellous femoral head allograft. Assessment of stiffness was followed by cyclic loading and load to failure tests. Resulting stiffness, fracture gap deflection and ultimate load were compared utilizing Bonferroni corrected t-test for independent samples. FINDINGS The mechanical effect of additional calcar screws was non-significant as compared to the basic screw configuration whereas bone block insertion significantly increased construct stiffness and failure load. The use of dynamic locking screws did not significantly reduce construct stiffness when compared to conventional locking screws. INTERPRETATION Additional calcar screws alone did not improve the initial biomechanical properties of an unstable 2-part proximal humeral fracture model. However bone block augmentation appeared to be a reliable alternative of additional bony support by raising stiffness and failure load. Dynamic locking screws did not show their expected dynamic component when used in a non-parallel arrangement.
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Affiliation(s)
- Jan Christoph Katthagen
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany.
| | - Michael Schwarze
- Laboratory of Biomechanics and Biomaterials, Medizinische Hochschule Hannover (MHH), Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - Josefin Meyer-Kobbe
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - Christine Voigt
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
| | - Christof Hurschler
- Laboratory of Biomechanics and Biomaterials, Medizinische Hochschule Hannover (MHH), Anna-von-Borries-Str. 1-7, 30625 Hannover, Germany
| | - Helmut Lill
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstr. 5, 30169 Hannover, Germany
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45
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Frich LH, Jensen NC. Bone properties of the humeral head and resistance to screw cutout. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2014; 8:21-6. [PMID: 24926160 PMCID: PMC4049036 DOI: 10.4103/0973-6042.131851] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Lars Henrik Frich
- Department of Orthopaedics, Odense University Hospital, Odense, Denmark
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Bai L, Fu ZG, Wang TB, Chen JH, Zhang PX, Zhang DY, Jiang BG. Radiological evaluation of reduction loss in unstable proximal humeral fractures treated with locking plates. Orthop Traumatol Surg Res 2014; 100:271-4. [PMID: 24709305 DOI: 10.1016/j.otsr.2013.12.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/10/2013] [Accepted: 12/31/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to radiologically evaluate the risk of reduction loss after locking plate fixation of proximal humerus fractures. METHODS From September 2007 to April 2009, 71 patients (28 males, 43 females) with unstable proximal humeral fracture were treated with open reduction and internal fixation by locking plate. The mean follow-up time was 31.2 months (range: 26-47). The head-shaft angulation (HSA) and the humeral head height (HHH) in true anteroposterior (AP) were recorded and compared over time. All complications were noted. Shoulder function was measured by the Constant score. RESULTS Patients with ΔHSA >10° (t=2.740, P=0.008) and ΔHHH >5mm (t=2.55, P=0.019) were more likely to have impaired shoulder function. Varus collapse occurred most frequently in patients with initial reduction of HSA <125° (χ(2)=19.17, P<0.001, Fisher's exact test F<0.001). Patients with >5mm HHH decrease were strongly associated with loss of reduction (χ(2)=24.23, P<0.001, F<0.001). CONCLUSIONS Dynamic change of HSA >10° and HHH >5mm were radiological factors that indicated poor shoulder function. Intra-operative HSA >125° should be achieved to avoid reduction loss following locking plate fixation of proximal humerus fracture. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
- L Bai
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - Z-G Fu
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - T-B Wang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - J-H Chen
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - P-X Zhang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - D-Y Zhang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China.
| | - B-G Jiang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China.
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Aziz MSR, Nicayenzi B, Crookshank MC, Bougherara H, Schemitsch EH, Zdero R. Biomechanical Measurements of Stiffness and Strength for Five Types of Whole Human and Artificial Humeri. J Biomech Eng 2014; 136:051006. [DOI: 10.1115/1.4027057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 04/10/2014] [Indexed: 11/08/2022]
Abstract
The human humerus is the third largest longbone and experiences 2–3% of all fractures. Yet, almost no data exist on its intact biomechanical properties, thus preventing researchers from obtaining a full understanding of humerus behavior during injury and after being repaired with fracture plates and nails. The aim of this experimental study was to compare the biomechanical stiffness and strength of “gold standard” fresh-frozen humeri to a variety of humerus models. A series of five types of intact whole humeri were obtained: human fresh-frozen (n = 19); human embalmed (n = 18); human dried (n = 15); artificial “normal” (n = 12); and artificial “osteoporotic” (n = 12). Humeri were tested under “real world” clinical loading modes for shear stiffness, torsional stiffness, cantilever bending stiffness, and cantilever bending strength. After removing geometric effects, fresh-frozen results were 585.8 ± 181.5 N/mm2 (normalized shear stiffness); 3.1 ± 1.1 N/(mm2 deg) (normalized torsional stiffness); 850.8 ± 347.9 N/mm2 (normalized cantilever stiffness); and 8.3 ± 2.7 N/mm2 (normalized cantilever strength). Compared to fresh-frozen values, statistical equivalence (p ≥ 0.05) was obtained for all four test modes (embalmed humeri), 1 of 4 test modes (dried humeri), 1 of 4 test modes (artificial “normal” humeri), and 1 of 4 test modes (artificial “osteoporotic” humeri). Age and bone mineral density versus experimental results had Pearson linear correlations ranging from R = −0.57 to 0.80. About 77% of human humeri failed via a transverse or oblique distal shaft fracture, whilst 88% of artificial humeri failed with a mixed transverse + oblique fracture. To date, this is the most comprehensive study on the biomechanics of intact human and artificial humeri and can assist researchers to choose an alternate humerus model that can substitute for fresh-frozen humeri.
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Affiliation(s)
- Mina S. R. Aziz
- Institute of Medical Science, University of Toronto, Toronto, ON M5S-1A8, Canada
- Martin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, ON M5B-1W8, Canada
| | - Bruce Nicayenzi
- Martin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, ON M5B-1W8, Canada
| | - Meghan C. Crookshank
- Martin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, ON M5B-1W8, Canada
| | - Habiba Bougherara
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B-2K3, Canada
| | - Emil H. Schemitsch
- Martin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Toronto, ON M5B-1W8, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON M5S-1A8, Canada
| | - Radovan Zdero
- Martin Orthopaedic Biomechanics Lab, St. Michael's Hospital, Li Ka Shing Building (West Basement, Room B116), 209 Victoria Street, Toronto, ON M5B-1W8, Canada
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON M5B-2K3, Canada e-mail:
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Aziz MSR, Tsuji MRS, Nicayenzi B, Crookshank MC, Bougherara H, Schemitsch EH, Zdero R. Biomechanical measurements of stopping and stripping torques during screw insertion in five types of human and artificial humeri. Proc Inst Mech Eng H 2014; 228:446-455. [DOI: 10.1177/0954411914529946] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
During orthopedic surgery, screws are inserted by “subjective feel” in humeri for fracture fixation, that is, stopping torque, while trying to prevent accidental over-tightening that causes screw–bone interface failure, that is, stripping torque. However, no studies exist on stopping torque, stripping torque, or stopping/stripping torque ratio in human or artificial humeri. This study evaluated five types of humeri, namely, human fresh-frozen (n = 19), human embalmed (n = 18), human dried (n = 15), artificial “normal” (n = 13), and artificial “osteoporotic” (n = 13). An orthopedic surgeon used a torque screwdriver to insert 3.5-mm-diameter cortical screws into humeral shafts and 6.5-mm-diameter cancellous screws into humeral heads by “subjective feel” to obtain stopping and stripping torques. The five outcome measures were raw and normalized stopping torque, raw and normalized stripping torque, and stopping/stripping torque ratio. Normalization was done as raw torque/screw–bone interface area. For “gold standard” fresh-frozen humeri, cortical screw tests yielded averages of 1312 N mm (raw stopping torque), 30.4 N/mm (normalized stopping torque), 1721 N mm (raw stripping torque), 39.0 N/mm (normalized stripping torque), and 82% (stopping/stripping torque ratio). Similarly, fresh-frozen humeri gave cancellous screw average results of 307 N mm (raw stopping torque), 0.9 N/mm (normalized stopping torque), 392 N mm (raw stripping torque), 1.2 N/mm (normalized stripping torque), and 79% (stopping/stripping torque ratio). Of the five cortical screw parameters for fresh-frozen humeri versus other groups, statistical equivalence (p ≥ 0.05) occurred in four cases (embalmed), three cases (dried), four cases (artificial “normal”), and four cases (artificial “osteoporotic”). Of the five cancellous screw parameters for fresh-frozen humeri versus other groups, statistical equivalence (p ≥ 0.05) occurred in five cases (embalmed), one case (dried), one case (artificial “normal”), and zero cases (artificial “osteoporotic”). Stopping/stripping torque ratios were relatively constant for all groups at 77%–88% (cortical screws) and 79%–92% (cancellous screws).
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Affiliation(s)
- Mina SR Aziz
- Martin Orthopaedic Biomechanics Lab, Li Ka Shing Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Matthew RS Tsuji
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce Nicayenzi
- Martin Orthopaedic Biomechanics Lab, Li Ka Shing Institute, St. Michael’s Hospital, Toronto, ON, Canada
| | - Meghan C Crookshank
- Martin Orthopaedic Biomechanics Lab, Li Ka Shing Institute, St. Michael’s Hospital, Toronto, ON, Canada
| | - Habiba Bougherara
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON, Canada
| | - Emil H Schemitsch
- Martin Orthopaedic Biomechanics Lab, Li Ka Shing Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Radovan Zdero
- Martin Orthopaedic Biomechanics Lab, Li Ka Shing Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Mechanical and Industrial Engineering, Ryerson University, Toronto, ON, Canada
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Ponce BA, Thompson KJ, Raghava P, Eberhardt AW, Tate JP, Volgas DA, Stannard JP. The role of medial comminution and calcar restoration in varus collapse of proximal humeral fractures treated with locking plates. J Bone Joint Surg Am 2013; 95:e113(1-7). [PMID: 23965707 DOI: 10.2106/jbjs.k.00202] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humeral fractures that are treated with locked plate constructs remain susceptible to collapse into a varus position. The objectives of the present study were to examine how medial comminution affects fracture stability and to determine the effect of calcar fixation on osteosynthesis stability. METHODS Eleven matched pairs of cadaveric humeri were osteotomized to create standard three-part fractures involving the surgical neck and the greater tuberosity. Five matched pairs were randomly assigned to have the medial calcar region remain intact. Six matched pairs had removal of a 10-mm medially based wedge of bone to simulate medial comminution. All fractures were stabilized in a uniform fashion with a proximal humeral locking plate. The constructs were secured, and the superior portion of the humeral head was subjected to compressive loading to induce varus collapse. Load-to-failure and energy-to-failure values along with stiffness and displacement at the time of failure were determined. RESULTS Medial comminution decreased the mean load to failure by 48% (523 N) (p = 0.015) and the mean energy to failure by 44% (2009 Nmm) (p = 0.013). The use of calcar screw fixation increased the mean load to failure by 31% (219 N) (p = 0.002) and the mean energy to failure by 44% (1279 Nmm) (p = 0.006). CONCLUSIONS Medial comminution significantly decreased the stability of proximal humeral fracture fixation constructs. Calcar restoration with screw fixation significantly improved the stability of repaired fractures in cadaveric specimens. CLINICAL RELEVANCE The data suggest that medial comminution is a predictor of poor stability of proximal humeral fractures and that stability may be improved through calcar restoration.
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Affiliation(s)
- Brent A Ponce
- Division of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL 35205, USA.
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Berkes MB, Little MTM, Lorich DG. Open reduction internal fixation of proximal humerus fractures. Curr Rev Musculoskelet Med 2013; 6:47-56. [PMID: 23321803 DOI: 10.1007/s12178-012-9150-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The treatment of proximal humerus fractures continues to evolve. While the many of these injuries can be managed nonoperatively, a certain percentage require operative treatment. Open reduction internal fixation can offer excellent outcomes when performed in the appropriate patient and utilizing proper techniques. This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes.
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Affiliation(s)
- Marschall B Berkes
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
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