Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years

Treatment of proximal humeral fractures accompanied by medial calcar fractures using fibular autografts: A retrospective, comparative cohort study

BACKGROUND

Severe proximal humerus comminuted fractures are often accompanied by medial calcar comminuted fractures and loss of medial support, which are important factors that lead to internal fixation failure. The appropriate treatment for proximal humerus comminuted fractures has not been established. Therefore, this study assessed the outcomes of using a fibular autograft with locking plates to treat severe proximal humerus comminuted fractures.

AIM

To investigate the outcomes of using a fibular autograft with locking plates to treat severe proximal humerus comminuted fractures.

METHODS

This retrospective, comparative cohort study included two groups of patients. Group 1 comprised 22 patients and group 2 comprised 25 patients with complete follow-up data. Group 1 was treated with a fibular autograft with open reduction and locking plates to enable internal fixation. Group 2 was treated with open reduction and locking plates to enable internal fixation. The intraoperative blood loss volume from the shoulder wound, operative time, shoulder wound pain, bone fracture healing time, Constant-Murley score of the shoulder joint, preoperative Holden walking function score, Mallet score of the shoulder joint, and humeral neck-shaft angle during surgery of the two groups were compared, and the differences were analysed using an independent sample t-test.

RESULTS

Group 1 had a shorter mean operative time than group 2 (2.25 ± 0.30 h vs 2.76 ± 0.44 h; P = 0.000). Group 1 had a lower shoulder wound pain score on the first day after surgery than group 2 (7.91 ± 1.15 points vs 8.56 ± 1.00 points; P = 0.044). Group 1 had a shorter fracture healing time than group 2 (2.68 ± 0.48 mo vs 3.64 ± 0.64 mo; P = 0.000). Group 1 had higher Constant-Murley scores of the shoulder joint at 3, 6, and 12 mo after surgery than group 2 (76.64 ± 4.02 points vs 72.72 ± 3.02 points, 86.36 ± 3.53 points vs 82.96 ± 3.40 points, and 87.95 ± 2.77 points vs 84.68 ± 2.63 points, respectively; P = 0.000, 0.002, and 0.000, respectively). Group 1 had higher Mallet scores of the shoulder joint at 3, 6, and 12 mo after surgery than group 2 (10.32 ± 0.57 points vs 9.96 ± 0.54 points, 13.36 ± 1.00 points vs 12.60 ± 0.87 points, and 13.91 ± 0.75 points vs 13.36 ± 0.70 points, respectively; P = 0.032, 0.007, and 0.013, respectively).

CONCLUSION

Using locking plates with a fibular autograft can recreate medial support, facilitate fracture healing, and improve shoulder function; therefore, this may be an effective treatment option for severe proximal humerus comminuted fractures.

The effect of integrity of lesser tuberosity-medial calcar on postoperative outcome in the proximal humeral fracture

BACKGROUND

In proximal humeral fractures, the medial calcar is often considered an important stabilizing structure. When the medial calcar is disrupted, some patients may have accompanying humeral lesser tuberosity comminution that has not been noticed. To investigate the impacts of comminuted fragments of lesser tuberosity and calcar on postoperative stability, CT results, number of fragments, cortical integrity, and the variation of neck-shaft angle were compared in patients with proximal humeral fractures.

MATERIALS AND METHODS

From April 2016 to April 2021, this study included patients with senile proximal humeral fractures diagnosed by CT three-dimensional reconstruction with lesser tuberosity fractures and medial column injuries. The number of fragments in the lesser tuberosity and the continuity of medial calcar were evaluated. Postoperative stability and shoulder function were evaluated by comparing changes in neck-shaft angle and the DASH upper extremity function score from 1 week to 1 year after the operation.

RESULTS

A total of 131 patients were included in the study, and the results showed that the number of fragments of the lesser tuberosity was related to the integrity of the medial cortex of the humerus. That is, when there were more than two lesser tuberosity fragments, the integrity of humeral medial calcar was poor. The positive rate of the lift-off test was higher in patients with lesser tuberosity comminutions 1 year after surgery. In addition, patients with more than two lesser tuberosity fragments and continuous destruction of the medial calcar had large variations in the neck-shaft angle, high DASH scores, poor postoperative stability, and poor recovery of shoulder joint function 1 year postoperatively.

CONCLUSION

The number of humeral lesser tuberosity fragments and the integrity of the medial calcar were associated with the collapse of the humeral head and the decrease in shoulder joint stability after the proximal humeral fracture surgery. When the number of lesser tuberosity fragments was greater than two and the medial calcar was damaged, the proximal humeral fracture had poor postoperative stability and poor functional recovery of the shoulder joint, which required auxiliary internal fixation treatment.

Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients

(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.

Treatment Reality of Proximal Humeral Fractures in the Elderly-Trending Variants of Locking Plate Fixation in Germany

BACKGROUND

The surgical treatment of proximal humeral fractures (PHFs) with locking plate fixation (LPF) in the elderly is associated with high complication rates, especially in osteoporotic bone. Variants of LPF such as additional cerclages, double plating, bone grafting and cement augmentation can be applied. The objective of the study was to describe the extent of their actual use and how this changed over time.

METHODS

Retrospective analysis of health claims data of the Federal Association of the Local Health Insurance Funds was performed, covering all patients aged 65 years and older, who had a coded diagnosis of PHF and were treated with LPF between 2010 and 2018. Differences between treatment variants were analyzed (explorative) via chi-squared or Kruskal-Wallis tests.

RESULTS

Of the 41,216 treated patients, 32,952 (80%) were treated with LPF only, 5572 (14%) received additional screws or plates, 1983 (5%) received additional augmentations and 709 (2%) received a combination of both. During the study period, relative changes were observed as follows: -35% for LPF only, +58% for LPF with additional fracture fixation and +25% for LPF with additional augmentation. Overall, the intra-hospital complication rate was 15% with differences between the treatment variants (LPF only 15%, LPF with additional fracture fixation 14%, LPF with additional augmentation 19%; p < 0.001), and a 30-day mortality of 2%.

CONCLUSIONS

Within an overall decrease of LPF by approximately one-third, there is both an absolute and relative increase of treatment variants. Collectively, they account for 20% of all coded LPFs, which might indicate more personalized treatment pathways. The leading variant was additional fracture fixation using cerclages.

Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults

PURPOSE

To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year.

METHODS

Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction.

RESULTS

A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs.

CONCLUSIONS

Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.

Plate osteosynthesis for proximal humerus fractures through a deltoid-split approach under traction in lateral decubitus position: preliminary results

Aim: We aimed to present deltoid split approach under traction in lateral decubitus position that we perform for the treatment of proximal humerus fractures (PHFs) and to present the preliminary surgical and clinical outcomes of our patients. Material and Method: Twelve patients who underwent plate osteosynthesis through a deltoid split approach under traction in lateral decubitus position between May 2019 and January 2021 were evaluated. Patient demographics, Neer classification, and time from injury to surgery were collected in all patients preoperatively. Radiation exposure time and operating time was recorded intraoperatively. Radiological outcomes were assessed, including time to union, and neck-shaft angle. Functional outcomes were evaluated using the Constant score at the minimum 12-month follow-up. Results: Twelve patients (5 male, 7 female) were evaluated with a mean age 58.6±10.7 years (range, 32 to 72 years) at the time of surgery. The mean follow-up period was 117.4±3.8 months). The mean operation time was 60.7±15.2 min (range, 44 to 92 min). The mean radiation exposure time was 6.1±3.0 s (range, 3.3 to 14.2 s). Fracture union was observed in all patients at mean 14.6±2.5 weeks (range, 8 to 20 weeks). The mean neck-shaft angle after the union was 134.5±3.4 degrees (range, 124 to 143 degrees). The mean Constant score was at the final follow-up was 76.4±8.7 (range, 63 to 90). Conclusion: Patient positioning in the lateral decubitus position under traction can be considered as a safe, reliable, and reproducible method in selected patients with PHFs.

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

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

Renal disease is a risk factor for complications and mortality after open reduction internal fixation of proximal humerus fractures

Background

Renal osteodystrophy predisposes renal disease patients to fracture. Proximal humerus fractures (PHFs) frequently undergo open reduction internal fixation (ORIF); however, the effect of renal disease on outcomes is unknown.

Methods

A retrospective review of the Nationwide Readmissions Database used International Classification of Diseases, 9th Revision, codes to identify patients who underwent ORIF for closed PHF from 2010 to 2014 with no renal disease, predialysis chronic renal disease (CRD), and end-stage renal disease (ESRD).

Results

A total of 85,433 patients were identified, including 5498 (6.4%) CRD and 636 (0.7%) ESRD. CRD and ESRD patients had increased age, comorbidities, and rates of Medicare insurance. After adjusting for differences, CRD and ESRD patients were at increased risk of any complication (odds ratio [OR] 2.48, 1.66), blood transfusion (OR 1.85, 3.31), respiratory complications (OR 1.14, 1.59), acute renal failure (OR 4.80, 1.67), systemic infection (OR 2.00, 3.14), surgical site infection (OR 1.52, 3.87), longer length of stay (7.1 and 12.9 days vs. 5.9 days), and higher cost ($21,669 and $35,413 vs. $20,394) during index hospitalization, as well as surgical site infection (OR 1.43, 3.03) and readmission (OR 1.61, 3.69) within 90 days of discharge, respectively, compared with no renal disease patients. During index hospitalization, CRD patients also had increased risk for periprosthetic fracture (OR 4.97) and cardiac complications (OR 1.47), whereas ESRD patients had increased risk of mortality (OR 5.79), wound complication (2.67), and deep vein thrombosis (OR 16.70).

Conclusion

These findings suggest renal patients are at increased risk for complications after PHF ORIF, highlighting the importance of close perioperative monitoring and appropriate patient selection in this population, including strong consideration of nonoperative management.

[Current trends in reverse fracture arthroplasty]

The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.

Predictive Indicators for Complications of Proximal Humerus Fractures Treated with Locking Plate or Intramedullary Nail Fixation

Objective

The purpose of this study was to evaluate the best placement of calcar screws in proximal humerus fracture surgeries.

Methods

This retrospective cohort study included clinical and radiographic outcomes of 98 patients treated with proximal humerus fracture surgeries between January 2017 and June 2020. Demographic data of patients were obtained from medical records. The surgical and radiographic results were also collected: operation time, blood loss, time to surgery, fibular allograft, disruption of medial region hinge, Neer classification, and recovery of medial support. Patients were allocated into two groups: the locking plate group (n = 65) and the intramedullary nail group (n = 33). In this study, we proposed new predictive indicators, named horizontal ratio (HR) and vertical ratio (VR), to quantify the placement of calcar screws in these two groups. A receiver operating characteristic (ROC) analysis was conducted to display the accuracy of these indicators. Shoulder activity, visual scale analog (VAS) score, and Constant score were performed to evaluate postoperative clinical outcomes at 1 year follow‐up.

Results

In the multivariate logistic regression analysis, only time to surgery and effective medial support were considered statistically significant factors of postoperative complications (p < 0.05). Significant differences were observed between medial support and postoperative complications both in the locking plate group and the intramedullary nail group (p < 0.05). Only the vertical ratio of locking plate (VRLP) was a statistically significant predictor of postoperative complications (p < 0.05). The area under curve was calculated to assess the predictive value of VRLP, which came to 0.84. In addition, a ROC analysis found quantifiable thresholds of the VR was 0.1713 as measures to avoid postoperative complications in the locking plate fixation.

Conclusion

In locking plate fixation, the incidence of postoperative complications increased significantly when the VR of calcar screws greater than 0.1713, which was beneficial to surgeons to place calcar screws.

Application of a lateral intertubercular sulcus plate in the treatment of proximal humeral fractures: a finite element analysis

Background

Inversion deformities caused by insufficient medial support are especially common when the PHILOS locking plate is used to treat proximal humeral fractures. Using finite element analysis, we aimed to compare the biomechanical properties of a PHILOS locking plate (PLP) and a PLP combined with a lateral intertubercular sulcus plate (PLP-LSP) in the fixation of proximal humeral fractures with loss of the medial column.

Methods

After creating a three-dimensional finite element model of a proximal humeral fracture with loss of the medial column, three implant models were established. A full-screw PLP was used in Group A, a PHILOS plate lacking medial screw support and an additional steel plate (MPLP-LSP) were used in Group B, and a full-screw PLP-LSP was used in Group C. The three fixation models were applied to the proximal humeral fracture model, following which horizontal, compressive, and rotational loads were applied to the humerus model. We evaluated structural stiffness and stress distribution in the implant and compared displacement and angle changes among the three models.

Results

Displacement and angle changes were smallest in Group C (PLP-LSP). The implant model used in Group C also exhibited greater structural rigidity, endured less von Mises stress, and was more stable than the models used in Group A and Group B.

Conclusion

An LSP placed at the intertubercular sulcus provides effective lateral and medial support, thereby reducing stress on the PLP and providing better stability with proximal humeral fractures.

Pegs not superior to screws for fixation of fractures of the proximal humerus

Background

Angular stable plates were introduced two decades ago as a promising treatment for fixation of displaced fractures of the proximal humerus (PHF). However, high rates of adverse events and reoperations have been reported. One frequent reason is secondary penetration of screws into the glenohumeral joint, due to sinking of the fracture or avascular head necrosis. To prevent joint penetrations angular stable plates with smooth locking pegs instead of locking screws have been developed. The aim of the present study was to investigate whether blunt pegs instead of pointed screws reduced the risk of secondary penetration into the glenohumeral joint during fracture healing after operatively treated PHFs.

Methods

From two different patient cohorts with displaced PHFs (60 treated with PHILOS plate with screws and 50 with ALPS-PHP plate with pegs), two groups were matched according to fracture type AO/OTA 11-B2 and 11-C2 and age (55–85 years). They were followed up at 3, 6 and 12 months. Primary outcome was radiographic signs of peg or screw penetrations into the glenohumeral joint at 12 months. Secondary outcomes were Oxford shoulder score (OSS) and Constant Score (CS) and radiographic signs of avascular humeral head necrosis (AVN).

Results

Eighteen PHILOS patients with B2 and C2 fractures could be matched with a corresponding group of 18 operated with ALPS-PHP with pegs. The number of penetrations of pegs and screws were equal between the two groups and the development of avascular head necrosis did not differ either. The functional outcomes for both OSS and CS at 12 months was clearly in favor of patients without joint penetrations in both groups.

Conclusion

We found no differences in the number of screw or peg penetrations in the PHILOS and ALPS-PHP group and the occurrence of AVN was equal. Joint penetrations led to inferior functional outcomes at 1 year.

The ClinicalTrials.gov identifier 20/11/12 prospectively for the Philos Group is NCT01737060, and for the ALPS group 11/03/20 retrospectively is NCT04622852.

Displaced Humeral Head After Intramedullary Nailing for Proximal Humeral Fracture is Associated With the Worse Short-term Outcomes -multicenter (TRON) study-

Background

In recent years, complex and unstable proximal humeral fractures (PHFs) are treated with intramedullary nails (IMNs) in the elderly; however, the postoperative radiographic findings related to the clinical outcome are not clear. This study evaluated the association of clinical outcomes with the radiographic findings of PHFs treated with IMNs.

Methods

We collected data of patients aged >60 years with PHFs treated with IMNs from 2015 to 2019 in 13 associated centers' database (named TRON). We excluded patients lost to follow-up of <6 months postoperatively (PO6M). We evaluated clinical outcomes with the University of California at Los Angeles (UCLA) score at PO6M and defined a score of <27 as poor. We assessed the radiographic findings on the anteroposterior view of the humeral head postoperatively, and each radiographic finding such as humeral head height (HHH), head shaft angle, and cranialization of the greater tuberosity was divided into two groups: poor and good. Factors associated with poor UCLA at PO6M were extracted by logistic regression analysis, and the factors were divided into two groups (poor and good) and matched for age, sex, and fracture type. The UCLA score at PO6M between the groups was examined by the Mann-Whitney U test, and the significance level was set at 0.05. The minimal clinical important difference in the UCLA score was set 2 points.

Results

The study included 243 patients (mean age, 76 years; range, 60-95 years). The mean follow-up period was 12 months (range, 6-56 months). The correlation coefficients indicated that there was either no or only a weak correlation between HHH, head shaft angle, and cranialization of the greater tuberosity. A poor HHH (HHH <0 or >10 mm) was extracted as a factor associated with a poor UCLA score at PO6M by logistic regression analysis (odds ratio: 5.78, 95% confidence interval = 1.2-27.7, P = .0287). In matched pair analysis, the UCLA score at PO6M was significantly lower in the poor HHH group (26 [range: 9-33] vs. 24 [range: 10-35], P = .0458).

Conclusion

We revealed that the HHH was an independent risk factor for poor short-term outcomes. There was a significant difference in the UCLA score between groups divided by the HHH in cases treated with IMNs. The HHH can be used intraoperatively or postoperatively as a reliable parameter to predict clinical outcomes in PHFs treated with IMNs.

MutiLoc Nail Versus Philos Plate in Treating Proximal Humeral Fractures: A Retrospective Study Among the Alderly

Background

Proximal humeral fractures (PHFs) account for 4–5% of all fractures in the elderly. There is still a controversy among the treatments in the displaced PHFs. Our aim was to explore the clinical outcome of PHFs with the treatment of MultiLoc nail or Philos plate in the elderly patients.

Methods

A total of 82 sustained elderly patients with PHFs were finally recruited between Dec 2016 and Dec 2017. 34 patients were treated with MultiLoc nail and 48 patients were treated with Philos plate. The demographics, fracture types, blood loss, operation time, union time, postoperative complications, visual analog scores (VASs), Constant scores, American Shoulder and Elbow Scores (ASESs), and neck-shaft-angle (NSA) between the two groups were compared.

Results

No differences were observed in the demographics, fracture types, VAS, Constant scores, and ASES scores between the two groups at final follow-up. Compared with the plate group, the blood loss, operation time, and union time were significantly lower in the nail group (all P < .05). The rate of general complications was 54.17% in the plate group, which was higher than that in the nail group (26.47%, P = .01). Three patients experienced reoperation in the plate group (3/48; 6.25%), but none in the nail group. Although there were no significant differences in intraoperative NSA between the two groups, the NSA at final follow-up in the nail group was much higher than the plate group (137.55 ± 5.53°vs 134.47 ± 5.92°, P = .02).

Conclusions

Multiloc intramedullary nail showed the similar effectiveness of final VAS, final Constant scores, and ASES scores in PHFs treatment with Philos plate. However, MultiLoc nail is superior to Philos plate in blood loss, operation time, complications, reoperation rate, and the change of NSA.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

INTRODUCTION

A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures.

PATIENTS AND METHODS

Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value.

RESULTS

After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported.

DISCUSSION

Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

PHILOS Plate Plus Oblique Insertion of Autologous Fibula for 2-Part Proximal Humerus Fractures With Medial Column Disruption: A Retrospective Study

Introduction:

The aim of this retrospective study was to evaluate the outcomes of older patients with 2-part proximal humerus fractures (PHFs) with medial column disruption stabilized using a proximal humeral internal locking system (PHILOS) plate plus oblique insertion of autologous fibula as a primary procedure.

Materials and Methods:

Data involving 112 patients (112 shoulders) sustaining 2-part PHFs with medial column disruption treated with PHILOS plate plus oblique insertion of autologous fibula as a primary procedure during 2012-2019 were identified. The median follow-up was 36 months (range: 11.2-43.5 months). The primary endpoint was the Constant scores and American Shoulder and Elbow Surgeons (ASES) scores. The secondary endpoint was the main orthopedic complication rate.

Results:

The median Constant and ASES scores were 78 (range, 52-95) and 77 (range, 62-96) at the final follow-up, respectively. The main orthopedic complication rate was 10.7% (12/112). Twelve orthopedic complications in 8 patients were detected, and they involved loss of reduction, varus collapse, aseptic loosening, mal-union, revision, and intolerable shoulder pain. Of these complications, 3 (2.6%) involved loss of reduction, 2 (1.7%) involved varus collapse, 3 (2.6%) involved aseptic loosening, 1 (0.8%) involved mal-union, 2 (1.7%) required revision surgery, and 1 (0.8%) presented intolerable shoulder pain.

Conclusion:

PHILOS plate plus oblique insertion of autologous fibula as a primary procedure may yield good functional outcomes and a low rate of the main orthopedic complications.

DIPHOS® nail for proximal humeral fractures: our experience with more than 190 procedures and surgical tips

AIM

evaluate the outcome of proximal  humeral nailing over 5 years follow-up, focusing  on possible complications. Secondary endpoint is the description and analysis of some technical notes to simplify surgical procedure.

MATERIALS AND METHODS

the cohort is composed by 194 fractures fixed with short nail. Neer Classification was used to assess the type of fracture; Deltoid Tuberosity Index (DTI) was applied to verify local bone quality. Follow-up with X-rays and orthopaedic evaluation was conducted on every operated subject.

RESULTS

mean follow up of the study was 25.4 months. We registered an average CMS score of 84.66 points for 2-parts fractures, 79.05 points for 3-part fractures and 68.62 points for 4-parts fractures. We obtained radiographical healing in 95.9% of patients (186/194) after 2.7 months on average. We recorded "very good" / "good" results in 90.3% of 2-parts fractures, 88.5% of 3-parts fractures and 46.2% of 4-part fractures. Overall complication rate was 10.3% (20/194 nails).  Second surgery was performed in 8.2% (16/194) of cases.

CONCLUSION

intramedullary nailing is an effective treatment for 2 and 3-part fractures with relatively low incidence of complications, small surgical accesses and short surgical time. Future researches are necessary to analyze the results related to nailing in 4-fragment fractures, still uncertain and influenced by multiple factors. The presence of the intramedullary nail reduces the lever arm of the screws making the osteosynthesis more reliable. Modern nails guarantee angular stability for proximal cancellous screws and allows 1 or 2 screws at calcar level to get a valid medial support.

Role of Additional Inferomedial Supporting Screws in Osteoporotic 3-Part Proximal Humerus Fracture: Finite Element Analysis

INTRODUCTION

Importance of inferomedial supporting screws in preventing varus collapse has been investigated for the proximal humerus fracture. However, few studies reported the results of osteoporotic complex fracture. This study aimed to demonstrate the stress distribution pattern, particularly in osteoporotic 3-part proximal humerus fractures involving greater tuberosity (GT) with different screw configurations.

MATERIALS AND METHODS

Using the computed tomography (CT) images of 2 patients, who had osteoporosis and the other had normal bone density, 3-part fractures involving the GT, without medial support were reconstructed. To reflect the osteoporosis or real bone density, Hounsfield unit of CT scans were utilized. A force of 200 N was applied in 30° varus direction. The proximal screws were set in 2 ways: 6 screws without inferomedial supporting screws and 9 screws with inferomedial supporting screws. Qualitative and quantitative analysis of internal stress distribution were performed.

RESULTS

The most proximal part area near humeral head vertex and near the 1st screw's passage and tip had more stress concentrated in osteoporotic 3-part fractures. The stress distribution around the proximal screws was found near the GT fracture line and its lateral side, where the local max values located. Inferomedial supporting screws decreased these effects by changing the points to medial side from the GT. The ratio in osteoporotic bone model decreased to that in normal bone model when inferomedial supporting screws were applied (normal bone, 2.97%-1.30%; osteoporosis bone, 4.76%-1.71%).

CONCLUSIONS

In osteoporotic 3-part proximal humerus fracture, the stress distribution was concentrated on the area near the humeral vertex, 1st row screw tips, and lateral side region from the GT fracture line. Moreover, inferomedial supporting screws ensured that the stress distribution is similar to that in normal bone setting, particularly in osteoporotic condition.

Factors associated with maintaining reduction following locking plate fixation of proximal humerus fractures: a population-based retrospective cohort study

Background

Loss of reduction (LoR) can occur after locking plate fixation of proximal humerus fractures (PHFs). This study determined biomechanical features of fracture fixation associated with preventing LoR postoperatively. One-year reoperation rates were also compared between those with/without LoR.

Methods

Population-based administrative data for 359 adults treated using a locking plate for PHF between 2010 and 2016 were examined. Two trained assessors reviewed standardized shoulder radiographs. LoR (Yes/No) was defined as any fracture displacement >0.5 cm, and/or >10° change in neck-shaft angle (NSA) alignment relative to intraoperative imaging. Multiple logistic regression assessed how the following affected maintaining reduction: (1) sex, (2) age, (3) Neer classification, (4) shaft impaction (SI), (5) shaft medialization (SM), (6) calcar reduction (CR), (7) NSA alignment, and (8) screw use.

Results

LoR was seen in 79 (22%) patients. LoR was significantly associated with increasing age (odds ratio [OR] = 1.06/yr, P < .001), fracture severity (4-part vs. 2-part fracture; OR = 4.63, P = .001), and varus NSA alignment (<125° vs. ≥145°: OR = 5.6, P = .02; <125° vs. 125-145°, OR = 2.2, P = .02]). Patients achieving simultaneous SI, SM, and CR were significantly less likely (OR = 0.009, P < .001) to lose reduction, after controlling for age, fracture severity, and NSA alignment. If only SI was achieved, patients were still significantly less likely to lose reduction relative to achieving none of these mechanical features (OR = 0.17, P = .006). Reoperations were higher when LoR occurred (n = 26/77 [33.4%]) compared with no LoR (n = 20/276 [7.2%]) (P < .001).

Conclusions

SI was strongly associated with preventing LoR in patients treated using a locking plate for PHF. SI with concurrent SM, CR, and a neutral or valgus NSA had the lowest rates of LoR. LoR was associated with higher rates of reoperation.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate

BACKGROUND

Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology.

METHODS

Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years.

RESULTS

There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation.

CONCLUSIONS

ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

Screw configuration in proximal humerus plating has a significant impact on fixation failure risk predicted by finite element models

BACKGROUND

Proximal humeral fractures occur frequently, with fixed angle locking plates often being used for their treatment. No current quantitative evidence for the effect of different screw configurations exists, and the large number of variations makes biomechanical testing prohibitive. Therefore, we used an established and validated finite element osteosynthesis test kit to quantify the effect of variations in screw configuration on predicted failure risk of PHILOS plate fixation for unstable proximal humerus fractures.

METHODS

Twenty-six low-density humerus models were osteotomized to create malreduced unstable 3-part fractures that were virtually fixed with PHILOS plates. Twelve screw configurations were simulated: 6 using 2 screw rows, 4 using 3 rows, and 1 with either 8 or 9 screws. Three physiological loading cases were modeled and an established finite element analysis methodology was used. The average peri-screw bone strain, previously demonstrated to predict fatigue cutout failure, was used to compare the different configurations.

RESULTS

Significant differences in peri-screw strains, and thus predicted failure risk, were seen with different combinations. The 9-screw configuration demonstrated the lowest peri-screw strains. Fewer screw constructs showed lower strains when placed further apart. The calcar screws (row E) significantly (P < .001) reduced fixation failure risk.

CONCLUSION

Screw configurations significantly impact predicted cutout failure risk for locking plate fixations of unstable proximal humerus fractures in low-density bone. Although requiring clinical corroboration, the result of this study suggests that additional screws reduce peri-screw strains, the distance between them should be maximized whenever possible and the calcar screws should be used.

Biomechanical behavior of three types of fixation in the two-part proximal humerus fracture without medial cortical support

Background

The purpose of this study was to evaluate the role of a non-locking plate applied to the anteromedial surface of the proximal humerus on loads at the implant-bone interface of non-locking and locking lateral plate fixation of proximal humeral fractures with a medial gap.

Methods

Twenty synthetic humeri models were used. In fifteen, the proximal portion of the humerus was osteotomized to create a two-part surgical neck fracture, with a 10-mm medial gap and a 5-mm lateral gap; five models were controls. In the osteotomized humeri, five models were stabilized with a locking lateral plate (group L), five with a locking lateral plate and an anteromedial non-locking plate (group L+T), and five with a non-locking lateral plate and a non-locking anteromedial plate (group T+T). All humeri were tested under axial loading until catastrophic failure, which was characterized as complete closure of the medial gap. Stiffness was calculated using force vs. displacement curves. The data were analyzed via descriptive and inferential studies, at a 5% significance level.

Results

Statistically significant differences were seen among all the constructions. The combination of a lateral locking plate with an anteromedial non-locking plate (group L+T) was the stiffest construction, while the combination of a non-locking lateral plate with a non-locking anteromedial plate (group T+T) was the least stiff, even in comparison with a single locking lateral plate (p = 0.01). When the two groups which utilized a lateral locking plate (groups L+T and L) were compared, the group with additional anteromedial support demonstrated greater stiffness (p = 0.03), and stiffness values for the control group comprised of intact humeri models were even higher (p = 0.01).

Conclusion

Combining a lateral locking plate with a non-locking anteromedial plate provides a stiffer construction for fixation of unstable two-part proximal humerus fractures with a medial gap. Mechanical benefits of medial support with a second non-locking antero-medial plate seems to be related with better construct stability in terms of strength and fatigue, potentially reducing the risk of varus collapse of the humerus head and fracture healing disturbances.