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Contreras JJ, Meissner A, Valenzuela A, Liendo R, de Marinis R, Calvo C, Soza F. Straight antegrade humeral nailing and risk of iatrogenic injury of supraspinatus tendon footprint: An MRI study. Shoulder Elbow 2023; 15:72-80. [PMID: 37974613 PMCID: PMC10649480 DOI: 10.1177/17585732221150895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/18/2022] [Accepted: 12/28/2022] [Indexed: 11/19/2023]
Abstract
Background Straight antegrade humeral nailing (SAHN) is associated with excellent clinical results in proximal humerus fractures. The optimal entry point is the top of the humeral head. However, the anatomy is variable, and the entry point can affect supraspinatus tendon footprint (SSP-F) or fracture reduction. The aim of this study was to analyze the relationship between the SSP-F and SAHN entry point by analyzing magnetic resonance imaging (MRI) studies of the humerus. Methods In total 58 MRI studies of entire humerus were reviewed. The mean age was 51.6 ± 12.4 years, with 40 female patients. The distance between the SSP-F and the SAHN insertion point (critical distance: CD), the width of the footprint, and the neck-shaft angle (NSA) were measured. Univariate and multivariate analysis were performed. Results The mean CD was 7.51 mm ± 2.81 (0-12.9 mm) with 51.7% of proximal humerus "critical type" (CD <8 mm). The CD was found to be lower in females, with no difference found with varying age (62.5% "critical type"). CD correlated with NSA (linear regression). "Critical type" correlated with female gender and NSA (logistic regression). Discussion More than half of the humerus are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications.
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Affiliation(s)
- Julio J Contreras
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
- Shoulder and Elbow Unit, Instituto Traumatológico, Santiago, Chile
- Department of Orthopedics and Trauma, Universidad de Chile, Santiago, Chile
| | - Arturo Meissner
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Alfonso Valenzuela
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Rodrigo Liendo
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Rodrigo de Marinis
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Claudio Calvo
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Francisco Soza
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
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Willauschus M, Grimme S, Loose K, Rüther J, Millrose M, Biber R, Gesslein M, Bail HJ. Risk Factors and Clinical Outcomes after Antegrade Intramedullary Nailing in Proximal Humeral Fractures: Insights and Implications for Patient Satisfaction. J Pers Med 2023; 13:1224. [PMID: 37623474 PMCID: PMC10455597 DOI: 10.3390/jpm13081224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs. METHODS A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging. RESULTS Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (-11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures. CONCLUSION The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up.
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Affiliation(s)
- Maximilian Willauschus
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
| | - Sebastian Grimme
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
| | - Kim Loose
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
| | - Johannes Rüther
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
| | - Michael Millrose
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
- Department of Trauma Surgery and Sports Medicine, Garmisch-Partenkirchen Medical Centre, 82467 Garmisch-Partenkirchen, Germany
| | - Roland Biber
- Department of Traumatology, Clinic Dr. Erler gGmbH, 90429 Nuremberg, Germany;
| | - Markus Gesslein
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
| | - Hermann Josef Bail
- Department of Orthopedics and Traumatology, General Hospital Nuremberg, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany (J.R.); (H.J.B.)
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Lorange JP, Alamiri N, Marwan Y, Alshammari A, Hamdy RC, Bernstein M. Humerus Lengthening with a Motorized Intramedullary Nail: A Systematic Review of Outcomes and Complications. Strategies Trauma Limb Reconstr 2022; 17:165-171. [PMID: 36756294 PMCID: PMC9886034 DOI: 10.5005/jp-journals-10080-1568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/10/2022] [Indexed: 01/01/2023] Open
Abstract
Aim In the past decade, internal limb lengthening nails have gained popularity. In this study, we aim to systematically review the literature on humerus limb lengthening with a motorized intramedullary nail (MIN). We intend to assess the outcome and complications of this technique. Materials and methods A systematic review was performed in the following databases: PubMed, Embase, Web of Science, and the Journal of Limb Lengthening and Reconstruction. The inclusion criteria included limb lengthening of the humerus using an intramedullary nail, clinical studies, all levels of evidence, and no restriction to the date of publication. Results Our search yielded 239 journal articles. A total of nine articles remained relevant based on the inclusion and exclusion criteria. The total number of patients was 20, with 22 segments lengthened. The mean age of the patients was 20.8-year-old [standard deviation (SD), 12.0; range, 13-51]. The mean gained length was 5.7 cm (SD, 0.9; range, 5-7.5) with a mean distraction protocol of 0.82 mm/day (SD, 0.2; range, 0.6-1). The average duration of lengthening was 71.6 days (SD, 12.8; range, 50-93), and the mean duration of consolidation was 192.3 days (SD, 40.5; range, 120-228). Reported complications included a range of motion (ROM) limitation, hardware failure, and hypertrophic bone regeneration. Conclusion Humeral lengthening with an MIN provides favourable outcomes with low complication rates. Future high-level studies should focus on comparing long-term outcomes of humeral lengthening utilising internal and external fixation techniques. Clinical significance Humeral lengthening using MIN can be used safely. Each surgical approach and type of nail have different risks and benefits. These should be carefully discussed when planning the surgery. How to cite this article Lorange JP, Alamiri N, Marwan Y, et al. Humerus Lengthening with a Motorized Intramedullary Nail: A Systematic Review of Outcomes and Complications. Strategies Trauma Limb Reconstr 2022;17(3):165-171.
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Affiliation(s)
- Justin-Pierre Lorange
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nawaf Alamiri
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Yousef Marwan
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Abdullah Alshammari
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Reggie Charles Hamdy
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Mitchell Bernstein
- Department of Pediatric Orthopedic Surgery, Limb Deformity Unit, Shriners Hospital for Children, Montreal, Quebec, Canada; Division of Orthopaedic Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Matsumura N, Furuhata R, Nakamura T, Kimura H, Suzuki T, Iwamoto T. Blocking screw augmentation in intramedullary nailing for displaced surgical neck fractures of the proximal humerus. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:46-51. [PMID: 37588295 PMCID: PMC10426556 DOI: 10.1016/j.xrrt.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
A displaced surgical neck fracture can be a good indication for antegrade intramedullary nailing. However, nail insertion may result in malreduction and translational displacement of the humeral head fragment because of muscle traction and size discrepancies between the diameters of the medullary canal and the intramedullary nail. We used blocking screw augmentation in 20 fractures with residual medial displacement of the distal fragment after nail insertion to anatomically reduce displacement of the fracture and to maintain the reduced position before bone union. A blocking screw was placed percutaneously at the lateral side of the canal. Next, a straight intramedullary nail was reinserted medial to the blocking screw. Finally, the nail was locked both proximally and distally. All cases showed bone union without fixation failure at the time of the final follow-up. Blocking screw augmentation with intramedullary nailing is feasible for the treatment of humeral surgical neck fractures and is thought to be helpful for fracture reduction during surgery and stable fixation after surgery.
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Affiliation(s)
- Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryogo Furuhata
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takumi Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroo Kimura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taku Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takuji Iwamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Bu G, Sun W, Li J, Yang T, Li M, Wei W. MutiLoc Nail Versus Philos Plate in Treating Proximal Humeral Fractures: A Retrospective Study Among the Alderly. Geriatr Orthop Surg Rehabil 2021; 12:21514593211043961. [PMID: 34595046 PMCID: PMC8477691 DOI: 10.1177/21514593211043961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Guoyun Bu
- Department of Orthopedic, Tianjin Hospital, Tianjin, China
| | - Weitang Sun
- Department of Orthopedic, The 3rd People Hospital of Qingdao, Shandong Province, China
| | - Jian'an Li
- Department of Orthopedic, Tianjin Hospital, Tianjin, China
| | - Tao Yang
- Department of Orthopedic, Tianjin Hospital, Tianjin, China
| | - Mingxin Li
- Department of Orthopedic, Tianjin Hospital, Tianjin, China
| | - Wanfu Wei
- Department of Orthopedic, Tianjin Hospital, Tianjin, China
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Fang C, Yee DK, Wong TM, Fang E, Pun T, Lau TW, Wong J, Leung F, Liu R, Cheung CC, Tipoe GL, Leung F. Differences in soft tissue damage using a percutaneous versus open approach for antegrade straight humeral nailing: a quantitative and qualitative anatomical study. J Orthop Surg (Hong Kong) 2021; 29:23094990211010548. [PMID: 34008454 DOI: 10.1177/23094990211010548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Percutaneous insertion of third-generation straight humeral nails is a recent alternative to the conventional open method. Rather than splitting, retracting and subsequently repairing the supraspinatus fibers to visualize the humeral head entry site, the percutaneous approach utilizes a cannulated awl to enter the intramedullary canal through the supraspinatus fibers without visualizing internal shoulder structures. Despite recent evidence demonstrating satisfactory outcomes in the percutaneous method, the potential for iatrogenic injury to the rotator cuff and other shoulder structures is not fully understood. MATERIALS AND METHODS We performed an anatomical study of 46 shoulders in 23 cadavers to compare damage caused to internal shoulder structures between the open and percutaneous techniques. Dimensions and morphologies of supraspinatus and humeral head perforations were recorded. RESULTS The percutaneous technique produced greater latitudinal tearing (p = 0.002) and less longitudinal tearing (p < 0.001) of muscle fibers, however there was no difference in supraspinatus hole area (p = 0.748). The long head biceps tendon was within 3 mm of the bone entry hole in 13 (28%) shoulders, with one shoulder in the open group exhibiting full tendon transection. CONCLUSIONS Percutaneous insertion of intramedullary nails using a cannulated awl appears to produce similar soft tissue and bone entry site morphology as compared to the conventional open technique. The percutaneous method was associated with slightly greater latitudinal tearing, however the effects of this remain to be clarified through clinical studies. External rotation should be avoided during instrumentation to reduce the risk of biceps tendon transection.
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Affiliation(s)
- Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Dennis Kh Yee
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Tak Man Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Evan Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Terence Pun
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Tak Wing Lau
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Janus Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Felix Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
| | - Rong Liu
- School of Biomedical Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - Chun Chung Cheung
- School of Biomedical Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - George Lim Tipoe
- School of Biomedical Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - Frankie Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
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Johnston PS, Hatzidakis AM, Tagouri YM, Curran-Everett D, Sears BW. Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus. JSES Int 2020; 4:745-752. [PMID: 33345210 PMCID: PMC7738442 DOI: 10.1016/j.jseint.2020.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Neurovascular insult, nonunion, and iatrogenic rotator cuff injury are concerns when using an intramedullary nail (IMN) for proximal humerus fracture. The purpose of this study was to identify a reproducible starting point and intraoperative imaging for nail insertion optimizing nail depth, tuberosity screw position, and protecting the axillary nerve and rotator cuff insertion. Our hypothesis was that a more medialized starting point would protect soft tissue structures and improve locking screw positioning. Methods Ten fresh-frozen cadavers underwent antegrade IMN with Grashey and modified lateral “precipice” view imaging. A guidewire was positioned medial to the coracoacromial ligament (CAL) in 5 cadavers and lateral to the CAL in 5. Distances from the nail entry point to anatomic landmarks were measured. Anatomic and histologic evaluations were performed, characterizing the nail perforation zone. Radiographs were compared between groups. Results The medial CAL group had a greater distance of screw fixation to the axillary nerve, a shorter distance of greater tuberosity (GT) screw fixation at the rotator cuff insertion on the infraspinatus and teres minor tubercles, and greater screw spread with improved lesser tuberosity capture. Two laterally placed implants violated the rotator cuff tendon. Imaging demonstrated that the ideal starting pin position was medial to the articular margin at a distance equal to the width of the rotator cuff insertion footprint. Conclusions Medial placement optimized fixation of the GT, avoided violation of the rotator cuff tendon and footprint, and was associated with an increased distance of proximal locking screw to the axillary nerve.
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Gerich T, Mouton C, Jabbarian L, Weydert JP, Hoffmann A, Pape D, Seil R. The portal of Neviaser: a valid option for antegrade nailing of humerus fractures. J Exp Orthop 2020; 7:8. [PMID: 32114683 PMCID: PMC7049297 DOI: 10.1186/s40634-020-00222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/31/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction The objective of this retrospective non-randomized study was to evaluate the portal of Neviaser (PN) as an alternative approach in antegrade humeral nailing. Methods The surgical approach for the straight antegrade intramedullary nail (SAIN) was either the anterolateral delta-split (group 2, n = 79) or the portal of Neviaser (group 3, n = 27). Length of surgery and time of radiation were extracted from charts. Patients stabilized using the PN were followed for a clinical and radiological exam. At follow-up we evaluated the DASH (Disability of the Arm, Shoulder and Hand) and CMS (Constant-Murley Score). Results Between 10.2015 and 12.2018 191 proximal and diaphyseal humeral fractures were operated using either an angular stable extramedullary device (group 1, PHILOS®, n = 85) or a straight humeral nail (MultiLoc®, n = 106). Time of radiation and intervention followed a normal distribution. The mean length of surgery was 172.9 min (SD 91.5) in group 1, 121.5 min (SD 54.1) in group 2 and 96.4 min (SD 33.7) in group 3 (p < 0.01). Time of radiation was significantly different with 1.1 min (SD 0.6: group 1), 3.1 min (SD 1.6: group 2) and 2.9 min (SD 1.7: group 3) (p < 0.01). After a mean interval of 21.5 months (range 6–43 months) 14 / 27 patients of group 3 were available for a clinical and radiological follow-up. The mean DASH in group 3 was 25, the CMS reached 70. The age and sex weighted CMS mean value was 96%. Forward flexion was 131°, abduction 125°. The ratio of strength affected versus non-affected side was 4.4: 6.2 kg. Conclusions The portal of Neviaser is a feasible and safe approach and is an alternative to the anterolateral delta-split. Length of surgery and time of radiation were significantly shorter. Level of evidence IV
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Affiliation(s)
- Torsten Gerich
- Department of Orthopaedic Trauma, Centre Hospitalier de Luxembourg, 4, rue Barble, L-1210, Luxembourg, Luxembourg.
| | - Caroline Mouton
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - Lea Jabbarian
- Department of Public Health, Erasmus MC, P.O. Box 2040, Rotterdam, 3000, CA, Netherlands
| | - Jean-Paul Weydert
- Department of Physiotherapy, Centre Hospitalier de Luxembourg, 4, rue Barble, L-1210, Luxembourg, Luxembourg
| | - Alexander Hoffmann
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - Dietrich Pape
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
| | - Romain Seil
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg, 76 rue d'Eich, L-1460, Luxembourg, Luxembourg
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Schwarz AM, Hohenberger GM, Euler S, Weiglein AH, Riedl R, Kuchling S, Krassnig R, Plecko M. Straight proximal humeral nailing: Risk of iatrogenic tendon injuries with respect to different entry points in anatomical specimens. Injury 2018; 49:1750-1757. [PMID: 30017183 DOI: 10.1016/j.injury.2018.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of the study was to evaluate the relationship of implant-related injuries to the adjacent anatomical structures in a newer generation straight proximal humeral nail (PHN) regarding different entry points. The proximity of the proximal lateral locking-screws of the MultiLoc proximal humeral nail (ML PHN) may cause iatrogenic tendon injuries to the lateral edge of the bicipital humeral groove (BG) as reference point for the tendon of the long head of biceps brachii (LBT) as well as the lateral insertion of the infraspinatus tendon (IST). MATERIALS AND METHODS The study comprised n = 40 upper extremities. Nail application was performed through a deltoid approach and supraspinatus tendon (SSP) split with a ML PHN. All tests were performed in three different entry points. First nail (N1) - standard position in line with the humeral shaft axis; second nail (N2) - a more lateral entry point; third alternative (N3) - medial position, centre of the humeral head. After nail placement, each specimen was screened for potential implant-related injuries or worded differently hit rates (HR) to the BG and the IST. The distances to the anatomical structures were measured and statistically interpreted. RESULTS The observed iatrogenic IST injury rate was 17.5% (n = 7/40) for N1, 5% (n = 2/40) for N2 and 62.5% (n = 25/40) for N3, which was statistically significantly higher (p < 0.001). Regarding the BG, the evaluated HR was 7.5% (n = 3/40) for both N1 and N2. Only the nail placed in the head centre (N3) showed an iatrogenic injury rate of 20% (n = 8/40) (p < 0.062). No statistically significant association between humeral head size and the HR could be observed (head diameter: IST: p = 0.323, BG: p = 0.621; head circumference: IST: p = 0.167; BG: p = 0.940). For the IST and BG, all distances in nail positions N1 and N2 as well as N2 and N3 differ statistically significant (p < 0.001). CONCLUSIONS An entry point for nail placement in line or slightly laterally to the humeral shaft axis - but still at the cartilage - should be advocated.
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Affiliation(s)
| | - G M Hohenberger
- Department of Orthopaedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - S Euler
- Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - A H Weiglein
- Institute of Clinical Gross Anatomy, Medical University of Graz, Graz, Austria
| | - R Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - S Kuchling
- Institute of Clinical Gross Anatomy, Medical University of Graz, Graz, Austria; Department of Trauma Surgery, State Hospital Wolfsberg, Wolfsberg, Austria
| | - R Krassnig
- Department of Orthopaedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - M Plecko
- AUVA-Trauma Hospital Graz, Graz, Austria
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Euler SA, Petri M, Venderley MB, Dornan GJ, Schmoelz W, Turnbull TL, Plecko M, Kralinger FS, Millett PJ. Biomechanical evaluation of straight antegrade nailing in proximal humeral fractures: the rationale of the "proximal anchoring point". INTERNATIONAL ORTHOPAEDICS 2017; 41:1715-1721. [PMID: 28497166 DOI: 10.1007/s00264-017-3498-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Varus failure is one of the most common failure modes following surgical treatment of proximal humeral fractures. Straight antegrade nails (SAN) theoretically provide increased stability by anchoring to the densest zone of the proximal humerus (subchondral zone) with the end of the nail. The aim of this study was to biomechanically investigate the characteristics of this "proximal anchoring point" (PAP). We hypothesized that the PAP would improve stability compared to the same construct without the PAP. METHODS Straight antegrade humeral nailing was performed in 20 matched pairs of human cadaveric humeri for a simulated unstable two-part fracture. RESULTS Biomechanical testing, with stepwise increasing cyclic axial loading (50-N increments each 100 cycles) at an angle of 20° abduction revealed significantly higher median loads to failure for SAN constructs with the PAP (median, 450 N; range, 200-1.000 N) compared to those without the PAP (median, 325 N; range, 100-500 N; p = 0.009). SAN constructs with press-fit proximal extensions (endcaps) showed similar median loads to failure (median, 400 N; range, 200-650 N), when compared to the undersized, commercially available SAN endcaps (median, 450 N; range, 200-600 N; p = 0.240). CONCLUSIONS The PAP provided significantly increased stability in SAN constructs compared to the same setup without this additional proximal anchoring point. Varus-displacing forces to the humeral head were superiorly reduced in this setting. This study provides biomechanical evidence for the "proximal anchoring point's" rationale. Straight antegrade humeral nailing may be beneficial for patients undergoing surgical treatment for unstable proximal humeral fractures to decrease secondary varus displacement and thus potentially reduce revision rates.
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Affiliation(s)
- Simon A Euler
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria. .,The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO, 81657, USA. .,Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA.
| | - Maximilian Petri
- The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO, 81657, USA.,Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA.,Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Melanie B Venderley
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Grant J Dornan
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Werner Schmoelz
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Travis Lee Turnbull
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Michael Plecko
- Unfallkrankenhaus Graz, Göstinger Str. 24, 8020, Graz, Austria
| | - Franz S Kralinger
- Department of Trauma Surgery, Wilhelminenspital, Montlearstr. 37, 1160, Vienna, Austria
| | - Peter J Millett
- The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO, 81657, USA.,Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
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Euler SA, Hengg C, Boos M, Dornan GJ, Turnbull TL, Wambacher M, Kralinger FS, Millett PJ, Petri M. Computed tomography-based prediction of the straight antegrade humeral nail's entry point and exposure of "critical types": truth or fiction? J Shoulder Elbow Surg 2017; 26:902-908. [PMID: 28111180 DOI: 10.1016/j.jse.2016.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus. METHODS Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types. RESULTS Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found. CONCLUSION Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff.
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Affiliation(s)
- Simon A Euler
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria; The Steadman Clinic, Vail, CO, USA; Steadman Philippon Research Institute, Vail, CO, USA.
| | - Clemens Hengg
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria
| | - Matthias Boos
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Markus Wambacher
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Maximilian Petri
- The Steadman Clinic, Vail, CO, USA; Steadman Philippon Research Institute, Vail, CO, USA; Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
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Lengthening of the humerus with intramedullary lengthening nails-preliminary report. Strategies Trauma Limb Reconstr 2017; 12:99-106. [PMID: 28439819 PMCID: PMC5505882 DOI: 10.1007/s11751-017-0286-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 04/10/2017] [Indexed: 11/29/2022] Open
Abstract
Distraction osteogenesis of the humerus with fully implantable lengthening is now possible since the diameter of the available nails was reduced to 10 mm and below. We report on the first intramedullary lengthening cases of the humerus with two different lengthening devices (FITBONE and PRECICE). Two different approaches and implantation techniques were used. We retrospectively reviewed clinical and radiographic data and pointed out results, pitfalls and complications of the procedure. Four adult patients with relevant length discrepancy of the humerus were treated with fully implantable systems in two centers between 2012 and 2015. Three patients were treated with FITBONE by an antegrade approach; one patient had lengthening with a PRECICE and a retrograde approach. Average nail lengthening was 55 mm (40–65 mm), and the average duration of lengthening was 70 days (52–95 days). The average distraction index was 0.72 mm/day (range 0.4–1.0 mm/day) or 12.5 days/cm (range 8.0–16.2 days/cm). The average consolidation index was 33.6 days/cm (range 25–45 days/cm). There was an implant failure (arrest) with the PRECICE. After consolidation and exchange with a technically improved implant, the course of treatment was uneventful. In patients with antegrade lengthening shoulder abduction decreased, and in the patient with the retrograde approach it improved but elbow extension decreased marginally. Reduced motion of the adjacent joints can be a major problem in intramedullary lengthening of the humerus. This first case series in the field of a rare indication suggests that lengthening of the humerus by fully implantable lengthening nails might be a valuable alternative to lengthening with external fixation. Main advantage of the PRECICE technology is the possible shortening in-between of lengthening.
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Rotator Cuff-Sparing Approach for Antegrade Humeral Nailing With Biceps Tenodesis: A Technical Trick With Clinical Implications. J Orthop Trauma 2017; 31:e60-e65. [PMID: 27580320 DOI: 10.1097/bot.0000000000000684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Antegrade intramedullary nails are an established, effective method of fixation for humeral shaft fractures. One significant limitation of this technique is chronic postoperative shoulder pain, which is likely related to the standard approach that involves splitting the rotator cuff to gain access to the nail starting point. Furthermore, mounting evidence suggests that both the intra-articular portion of the biceps tendon and the extra-articular portion in the bicipital groove can scar down after trauma, causing pain and limiting shoulder range of motion. We describe an approach through the rotator interval with tenodesis of the biceps tendon and resection of the intra-articular portion. Using a rotator cuff interval instead of a rotator cuff insertion approach allows access to the optimal humeral nail starting point while avoiding damage to intra-articular structures of the shoulder, potentially decreasing sources of postoperative shoulder pain.
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Lindtner RA, Kralinger FS, Kapferer S, Hengg C, Wambacher M, Euler SA. The female geriatric proximal humeral fracture: protagonist for straight antegrade nailing? Arch Orthop Trauma Surg 2017; 137:1385-1390. [PMID: 28756586 PMCID: PMC5602045 DOI: 10.1007/s00402-017-2767-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Straight antegrade humeral nailing (SAHN) has become a standard technique for the surgical fixation of proximal humeral fractures, which predominantly affect elderly females. The nail's proximal anchoring point has been demonstrated to be critical to ensure reliable fixation in osteoporotic bone and to prevent iatrogenic damage to the superior rotator cuff bony insertion. Anatomical variations of the proximal humerus, however, may preclude satisfactory anchoring of the nail's proximal end and may bare the risk of rotator cuff violation, even though the nail is inserted as recommended. The aim of this study was to evaluate the anatomical suitability of proximal humeri of geriatric females aged 75 years and older for SAHN. Specifically, we sought to assess the proportion of humeri not anatomically amenable to SAHN for proximal humeral fracture. MATERIALS AND METHODS A total of 303 proximal humeri of 241 females aged 75 years and older (mean age 84.5 ± 5.0 years; range 75-102 years) were analyzed for this study. Multiplanar two-dimensional reformations (true ap, true lateral, and axial) were reconstructed from shoulder computed tomography (CT) data sets. The straight antegrade nail's ideal entry point, "critical point" (CP), and critical distance (CD; distance between ideal entry point and CP) were determined. The rate of proximal humeri not anatomically suitable for SAHN (critical type) was assessed regarding proximal reaming diameters of currently available straight antegrade humeral nails. RESULTS Overall, 35.6% (108/303) of all proximal humeri were found to be "critical types" (CD <8 mm) as to the recommended minimal proximal reaming diameter of 10 mm of straight antegrade nails currently in use. Moreover, 43.2% (131/303) of the humeri were considered "critical types" with regard to the alternatively used larger proximal reaming diameter of 11.5 mm. Mean CD was 9.0 ± 1.7 mm (range 3.5-13.5 mm) and did not correlate with age (r = -0.04, P = 0.54). No significant differences in CD and rate of "critical types" were found between left and right humeri as well as between females aged between 75 and 84 years (n = 151) and females aged 85 and older (n = 152). CONCLUSIONS More than a third of proximal humeri of geriatric females are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications, such as rotator cuff violation, fixation failure, and potential malreduction. In view of this finding, we recommend to routinely analyze multiplanar CT reformations of the uninjured contralateral side prior to surgery to improve selection of patients for SAHN and to minimize foreseeable complications. For "critical type" humeri, an alternative surgical procedure should be considered.
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Affiliation(s)
- Richard A. Lindtner
- 0000 0000 8853 2677grid.5361.1Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Franz S. Kralinger
- 0000 0004 0524 3028grid.417109.aDepartment of Trauma Surgery, Wilhelminenspital, Montlearstr. 37, 1160 Vienna, Austria
| | - Sebastian Kapferer
- 0000 0000 8853 2677grid.5361.1Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Clemens Hengg
- 0000 0000 8853 2677grid.5361.1Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Markus Wambacher
- 0000 0000 8853 2677grid.5361.1Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Simon A. Euler
- 0000 0000 8853 2677grid.5361.1Department of Trauma Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
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Ueyama H, Yano K, Kanemura M, Gotani H, Ito S, Sakanaka H. Clinical outcomes and prognostic factors depending on implant design in the treatment of proximal humeral fractures: A retrospective study. J Orthop 2016; 13:369-75. [PMID: 27486289 DOI: 10.1016/j.jor.2016.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/27/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE We aimed to examine the clinical outcomes of proximal humeral fractures treated with different intramedullary nail shapes. METHODS Thirty-seven patients were divided into two groups depending on the implant shape. We also defined F group as a subgroup of fracture classification. RESULTS In the F group, the flexion of the shoulder joint was significantly greater in S (mean, 134.6°) than in C groups (mean, 109°) (p = 0.04). The complication rate was significantly larger in the C group (p = 0.04). CONCLUSIONS Patients with one kind of fracture and who were treated with straight nails had better outcomes.
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Affiliation(s)
- Hideki Ueyama
- Department of Orthopedic Surgery, Seikeikai Hospital, Japan
| | - Koichi Yano
- Department of Orthopedic Surgery, Seikeikai Hospital, Japan
| | | | | | - Sadanao Ito
- Department of Orthopedic Surgery, Aeba Hospital, Japan
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Tamimi I, Montesa G, Collado F, González D, Carnero P, Rojas F, Nagib M, Pérez V, Álvarez M, Tamimi F. Displaced proximal humeral fractures: when is surgery necessary? Injury 2015; 46:1921-9. [PMID: 26120018 DOI: 10.1016/j.injury.2015.05.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/12/2015] [Accepted: 05/31/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Several therapeutic methods have been traditionally used in the treatment of displaced proximal humeral fractures; however, the indication of these treatments is still controversial. The purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, proximal humeral nails (PHN), percutaneous K-wiring (PKW), and locking-plates (LP)] taking into consideration the type of fracture and the age of the patients. METHODS We conducted a retrospective cohort study on patients with proximal humeral fractures treated with one of the following methods: conservative treatment, PHN, PKW, or LP. Functional results were assessed using the absolute Constant score and the disabilities of the arm shoulder and hand score (DASH). The functional outcome was analysed according to age (≥65 years and <65 years) and fracture type (displaced 2-fragment and 3-4-fragment fractures). RESULTS A total of 113 patients were included in the study, with a mean age of 65.3 SD 15.2 years and average follow-up time of 26.2 SD 12.6 months. Patients under 65 years had higher Constant scores when treated with PHN and PKW than those treated conservatively (77.2 vs. 54.7, p=0.01 and 74.0 vs. 54.7, p=0.03, respectively). Patients above 65 years had higher Constant scores when treated with PKW compared to PHN and conservative treatment (68.7 vs. 51.9, p=0.02 and 68.7 vs. 55.9, p=0.029, respectively). In 2-fragment fractures, PKW resulted in higher Constant scores than conservative treatment (70.4 vs. 53.9, p=0.048). No differences were found in the final outcome between patients treated with LP and those treated conservatively regardless of age, and fracture type. There were also no differences between any of the evaluated methods in the treatment of 3-4-fragment fractures. CONCLUSION The use of PKW was associated with better functional results than conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures; PKW also achieved better functional results than PHN in elderly patients. PHN was superior to conservative treatment in young individuals. No significant differences were found between LP and conservative treatment in any of the analysed categories.
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Affiliation(s)
| | - Guillermo Montesa
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Francisco Collado
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - David González
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Pablo Carnero
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Facundo Rojas
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Mohamed Nagib
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Verónica Pérez
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Miguel Álvarez
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Faleh Tamimi
- Faculty of Dentistry, McGill University, Montreal, Canada
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