Comparison of Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation on Proximal Humeral Fracture in Elder Patients: A Systematic Review and Meta-Analysis

Proximal humerus fractures: deltopectoral open reduction and internal fixation vs deltosplit minimally invasive plate osteosynthesis: which surgical approach provides superior results?

Purpose

To compare the two main surgical approaches to address proximal humerus fractures (PHFs) stratified for Neer fracture types, to demonstrate which approach gives the best result for each fracture type.

Methods

A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in PubMed, Web of Science, and Cochrane databases up to 4 January 2022. Inclusion criteria were studies comparing open reduction and internal fixation (ORIF) with deltopectoral (DP) approach and minimally invasive plate osteosynthesis (MIPO) with deltosplit (DS) approach of PHFs. Patient's demographic data, fracture type, Constant-Murley Score (CMS), operation time, blood loss, length of hospital stay, complications, fluoroscopy time, and radiological outcomes were extracted. Results were stratified for each type of Neer fracture.

Results

Eleven studies (798 patients) were included in the meta-analysis. No functional difference was found in the CMS between the two groups for each type of Neer (P = n.s.): for PHFs Neer II, the mean CMS was 72.5 (s.e. 5.9) points in the ORIF group and 79.6 (s.e. 2.5) points in the MIPO group; for Neer III, 77.8 (s.e. 2.0) in the ORIF and 76.4 (se 3.0) in the MIPO; and for Neer IV, 70.6 (s.e. 2.7) in the ORIF and 60.9 (s.e. 6.3) in the MIPO. The operation time in the MIPO group was significantly lower than in the ORIF group for both Neer II (P = 0.0461) and Neer III (P = 0.0037) fractures.

Conclusion

The MIPO with DS approach demonstrated no significant differences in the results to the ORIF with DP approach for the different Neer fractures in terms of functional results, with a similar outcome, especially for the Neer II and III fracture types. The MIPO technique proved to be as safe and effective as the ORIF approach.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Minimally invasive plate osteosynthesis: An update of practise

Since its conception in 1989, minimally invasive plate osteosynthesis (MIPO) has gained widespread popularity. It has been studied in over forty countries with most of the publications originating from Asia, Europe and North America. This review aims to describe the scientific path of MIPO from the very beginning to where it stands in current day times; study the pattern and contributing factors influencing its global spread. Finally, the up to date evidence is discussed with regard to several anatomical regions in which MIPO is mostly used. In the meantime, MIPO treads steadily towards accomplishing the same or better outcomes for more and more indications with the goal to leave a smaller surgical footprint to allow for undisturbed bone healing.

Deltopectoral vs. deltoid split approach for proximal HUmerus fracture fixation with locking plate: a prospective RAndomized study (HURA)

BACKGROUND

This study aimed to compare the functional and clinical outcomes between the deltoid split (DS) approach and the classic deltopectoral (DP) approach for locking plate fixation of proximal humerus fractures (PHF) in a prospective randomized multicenter study.

METHODS

From 2007 to 2015, all patients with a PHF Neer II/III were invited to participate. Exclusion criteria were pre-existing pathology to the limb, patient refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), and axillary nerve impairment. After consent, patients were randomized to one of the 2 treatments using the dark envelope method. Functional outcome was evaluated by validated questionnaires (12-Item Short Form Health Survey: version 2, Quick-DASH) with a minimum follow-up of 12 months. Complications were noted.

RESULTS

A total of 85 patients (44 DS, 41 DP) were randomized (mean age of 62). Groups were equivalent in terms of age, gender, body mass index, severity of fracture, and preinjury scores. The mean follow-up was 26 months. All clinical outcome measures were in favor of the deltopectoral approach. Specifically, the Q-DASH and SF-12v2 were better in the DP group (12 vs. 26, P = .003 and 56 vs. 51, P = .049, respectively). There were more complications in DS patients, but they did not reach statistical significance.

CONCLUSIONS

The primary hypothesis on the superiority of the deltoid split incision was rebutted. On the basis of our study, the DP approach seems to offer better function compared with the DS approach for fixation of Neer 2 and 3 PHF fractures fixed with a locking plate.

Perceptions of minimally invasive osteosynthesis: A 2018 survey of orthopedic surgeons

OBJECTIVE

To report perspectives of minimally invasive osteosynthesis (MIO) techniques in veterinary surgical practice in 2018.

STUDY DESIGN

Electronic questionnaires.

SAMPLE POPULATION

Diplomates and residents of the American College of Veterinary Surgery and European College of Veterinary Surgery and members of the Veterinary Orthopedic Society.

METHODS

Survey questions pertaining to MIO and minimally invasive plate osteosynthesis (MIPO) were sent electronically to the sample population. Questions assessed training, current caseload, benefits, and limitations of MIO and MIPO.

RESULTS

Two hundred fifty-six veterinary surgeons completed questions pertaining to MIO, and 238 veterinary surgeons completed questions pertaining to MIPO. With regard to MIO, only 16% of respondents reported that they performed MIO regularly or exclusively, and 62% wanted to perform more MIO than they were currently undertaking. Tibial fractures were most commonly selected for MIO/MIPO stabilization techniques in both cats and dogs. Challenges in achieving adequate fracture reduction were identified as the greatest limitations of MIO/MIPO techniques. Forty-three percent of respondents felt there were not enough MIPO training opportunities.

CONCLUSION

Currently, MIO/MIPO techniques are performed infrequently, with a large proportion of respondents revealing that they would like to perform more in the future. There is also evidence that additional training opportunities would be welcomed for MIPO.

CLINICAL SIGNIFICANCE

The results of our survey provide evidence that, despite the benefits of MIO and MIPO compared with more traditional fracture stabilization approaches, significant barriers must be overcome before the techniques are likely to be more widely adopted.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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