Philos plate fixation for proximal humeral fractures

Outcomes of Locking Plates in Proximal Humeral Fractures: A Systematic Review

A systematic review of the clinical and radiological outcomes of locking plates in proximal humeral fractures in the current English literature was performed using Medline, CINAHL, AMED and EMBASE electronic databases to July 2009 via Ovid. There were 1266 proximal humeral fractures included in the review. The mean age of the patients was 61.7 years and there were 70.3% women. Based on the Neer classification, the review included 27% two-part, 39.5% three-part and 23.6% four-part fractures. At final follow-up, the Constant score was in the range 59 to 80, and the Disabilities of the Arm, Shoulder and Hand scores were in the range 15.2 to 51.8. The most frequent postoperative complication described was intra-articular screw perforation in 8.5% of fractures. Other complications included avascular necrosis (5.1%), subacromial impingement (3.1%), loss of reduction (3.7%) and implant failure (3.15%). Unplanned secondary surgical procedures were undertaken in 14.2% of cases. This systematic review has demonstrated that locking plate systems are suitable for stabilizing proximal humeral fractures. The current evidence base presents a number of methodological weaknesses and randomized controlled trials at independent centres reporting long-term results are required to compare locking plate systems with alternative fixation techniques used in the treatment of proximal humeral fractures.

Outcome Analysis of Locking Plate Fixation in Proximal Humerus Fracture

INTRODUCTION

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The treatment of complex proximal humeral fractures: analysis of the results of 55 cases treated with PHILOS plate

Complex proximal humerus fractures are often difficult to treat. Their frequency is high, especially in the elderly, and their treatment is still controversial. The aim of this study was to analyze the clinical and radiological results achieved by patients with complex proximal humerus fractures, treated with PHILOS plate only. A cohort of 55 patients was selected. The mean age was 63.4 (range 33-89), while the mean follow-up time was 21.5 months (range 6-75). Clinical outcome was evaluated with the "Constant-Murley shoulder score." All the informations about the presence of complications were gathered, and radiological images were used to calculate the head-shaft angle. The overall mean Constant score was 61.93 ± 18.59, the Individual CS was 70 ± 20 % and the Relative CS was 83 ± 23 %. No significant differences were found between fractures Neer 3 and Neer 4 and between the surgical approaches (delta-split vs. delto-pectoral). Six patients had a fracture with dislocation, seven patients (12.7 %) had complications while in four patients a head-shaft angle beyond the normal range was found. Osteosynthesis with PHILOS plate is stable in the greater part of the cases, and it allows an earlier rehabilitation and so a good functional result, which could be compromised by a prolonged immobilization. Therefore, PHILOS plate is a good option for the treatment of complex proximal humerus fractures.

Comparing the treatment results of proximal humerus fracture based on surgical or nonsurgical methods

Background:

A common type of Humerus fractures is about proximal. This study aimed to compare the results of surgical and non-surgical methods in treatment the Fracture of Proximal Humerus for decisions based on high-performance and less side effect.

Materials and Methods:

This prospective clinical trial study was done on 114 patients 30-80 years old with proximal humerus fracture referred to the Isfahan hospital universities (Ayatollah Kashani and Al Zahra hospitals) in 2007-2012. They were divided into two groups of 57 and treated surgically or non-surgically. The self provided questionnaires were used to assess the consequences of the side effects. The patients returned for trial check up during 6 weeks, 3 months, 6 months and one year after intervention.

Result:

In two parts fracture with displacement, nonsurgical treatment had lead to more complications rather than surgical treatment. In three-parts fracture non-union was seen in nonsurgical method in 6 weeks and in surgical method in 3, 6 months and one year after treatment, malunion was seen more in nonsurgical method rather than surgical method. In four-part fracture none-union results was seen more in nonsurgical method in 6 weeks, 3 months and one year and in surgical method in 6 months after treatment, mal union was seen more in nonsurgical method rather than surgical method.

Conclusion:

The surgery in three and four parts fractures had fewer complications in the patients under 50 but not in the elders.

Biologic fixation through bridge plating for comminuted shaft fracture of the clavicle: technical aspects and prospective clinical experience with a minimum of 12-month follow-up

For comminuted shaft fracture of clavicle, the operative goal, aside from sound bone healing without complications of direct reduction, is maintenance of the original length in order to maintain the normal biomechanics of adjacent joint. Our bridge plating technique utilizing distraction through a lumbar spreader was expected to be effective for restoring clavicular length with soft tissue preservation. However, there are two disadvantages. First, there is more exposure to radiation compared to conventional plating; and second, it is difficult to control the rotational alignment. Despite these disadvantages, our technique has important benefits, in particular, the ability to preserve clavicular length without soft tissue injury around the fracture site.

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

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

The calcar screw in angular stable plate fixation of proximal humeral fractures--a case study

BACKGROUND

With new minimally-invasive approaches for angular stable plate fixation of proximal humeral fractures, the need for the placement of oblique inferomedial screws ('calcar screw') has increasingly been discussed. The purpose of this study was to investigate the influence of calcar screws on secondary loss of reduction and on the occurrence of complications.

METHODS

Patients with a proximal humeral fracture who underwent angular stable plate fixation between 01/2007 and 07/2009 were included. On AP views of the shoulder, the difference in height between humeral head and the proximal end of the plate were determined postoperatively and at follow-up. Additionally, the occurrence of complications was documented. Patients with calcar screws were assigned to group C+, patients without to group C-.

RESULTS

Follow-up was possible in 60 patients (C+ 6.7 ± 5.6 M/C- 5.0 ± 2.8 M). Humeral head necrosis occurred in 6 (C+, 15.4%) and 3 (C-, 14.3%) cases. Cut-out of the proximal screws was observed in 3 (C+, 7.7%) and 1 (C-, 4.8%) cases. In each group, 1 patient showed delayed union. Implant failure or lesions of the axillary nerve were not observed. In 44 patients, true AP and Neer views were available to measure the head-plate distance. There was a significant loss of reduction in group C- (2.56 ± 2.65 mm) compared to C+ (0.77 ± 1.44 mm; p = 0.01).

CONCLUSIONS

The placement of calcar screws in the angular stable plate fixation of proximal humeral fractures is associated with less secondary loss of reduction by providing inferomedial support. An increased risk for complications could not be shown.

Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus

BACKGROUND AND PURPOSE

There is considerable uncertainty about the optimal treatment of displaced 4-part fractures of the proximal humerus. Within the last decade, locking plate technology has been considered a breakthrough in the treatment of these complex injuries.

METHODS

We systematically identified and reviewed clinical studies on the benefits and harms after osteosynthesis with locking plates in displaced 4-part fractures.

RESULTS

We included 14 studies with 374 four-part fractures. There were 10 case series, 3 retrospective observational comparative studies, 1 prospective observational comparative study, and no randomized trials. Small studies with a high risk of bias precluded reliable estimates of functional outcome. High rates of complications (16-64%) and reoperations (11-27%) were reported.

INTERPRETATION

The empirical foundation for the value of locking plates in displaced 4-part fractures of the proximal humerus is weak. We emphasize the need for well-conducted randomized trials and observational studies.

Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone

BACKGROUND

Failure to achieve stable fixation with medial support in proximal humeral fractures can result in varus malalignment and cut-through of the proximal screws. The purpose of this study was to investigate the influence of an intramedullary fibula bone graft on the biomechanical properties of proximal humeral fractures stabilized by angular stable plate fixation in a bone model under cyclic loading.

METHODS

Two fixation techniques were tested in 20 composite analog humeri models. In group F- (n = 10), fractures were fixed by an anatomically formed locking plate system. In group F+ (n = 10), the same fixation system was used with an additional fibular graft model with a length of 6 cm inserted in an intramedullary manner. Active abduction was simulated for 400 cycles by use of a recently established testing setup. Fragment gap distance was measured, and thereby, intercyclic motion, fragment migration, and residual plastic deformation were determined.

RESULTS

The addition of a fibular graft to the fixation plate led to 5 times lower intercyclic motion, 2 times lower fragment migration, and 2 times less residual plastic deformation. Neither screw pullout, cut-through, nor implant failure was observed.

CONCLUSION

Medial support with an intramedullary fibular graft in an angular stable fixation of the proximal humerus in vitro increases overall stiffness of the bone-implant construct and reduces migration of the humeral head fragment. This technique might provide a useful tool in the treatment of displaced proximal humeral fractures, especially when there is medial comminution.

New trends in fixation of proximal humeral fractures: a review

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

Plating of proximal fracture of the humerus: a study of 30 cases

In recent years, plate osteosynthesis with angular stable implants is frequently used for severely displaced three- and four-part proximal humeral fractures. The aim of this study is to evaluate early results of these fractures treated with insertion of LCP or Philos plates. We present results in 30 cases of proximal humeral fractures, 17 with 3 parts according to Neer and 13 with 4 parts, treated with Locking Compression Plates (LCP, 14 cases) and Philos plates (16) by the deltopectoral approach. Patients were checked with standard X-rays and clinical evaluation, according to the Constant-Murley shoulder score, Individual Constant score and Relative Constant score. Mean follow-up time was 21 months (range 6-42 months). The mean Constant-Murley shoulder scores were Pain 10.6 (3-15), Activities of Daily Living 15.3 (2-20), Range of Motion 26.8 (12-40) and Power 10.3 (3-25) and Total 63 (25-97). The Individual Constant score was 68.6% (27-98%) and the Relative Constant score 85.4% (36-130%). Fractures in 3 parts (of the surgical or anatomic humeral neck and major tubercle) had a mean Constant score of 69.1 (17 cases), but this fell to 55 (13 cases) in those in 4 parts (neck, major and lesser tubercles). Late necrosis of the humeral head occurred in two cases, both with 4-part breaks. We thus believe that 3-part fractures, in which both reduction and stable osteosynthesis are easier, show favourable prognosis and should be clearly distinguished from 4-part ones during assessments. The deltopectoral approach offers good exposure and is especially recommended in 4-part fractures, also because it provides a good view of the lesser tubercle. The osteosynthesis must be stable if early mobilisation of the shoulder and proper recovery of range of motion are to be achieved. As well as reduction and stabilisation of the tubercles, it is also important to restore the neck/shaft angle and stabilise it with oblique screws fitting the plate to avoid varus malposition.