Intermediate outcomes following percutaneous fixation of proximal humeral fractures

Quantitative contrast enhanced dual energy CT to predict avascular necrosis: a feasibility study of proximal humerus fractures

BACKGROUND

Avascular necrosis is a delayed complication of proximal humerus fractures that increases the likelihood of poor clinical outcomes. CT scans are routinely performed to guide proximal humerus fracture management. We hypothesized iodine concentration on post-contrast dual energy CT scans identifies subjects who develop avascular necrosis and ischemia due to compromised blood flow.

MATERIALS AND METHODS

55 patients with proximal humerus fractures enrolled between 2014 and 2017 underwent clinical, radiographic and contrast enhanced dual energy CT assessment. Iodine densities of the humeral head and the glenoid (control) were measured on CT. Subjects managed with open reduction internal fixation or conservatively (non-surgical) were followed for up to two years for radiographic evidence of avascular necrosis. Arthroplasty subjects underwent histopathologic evaluation for ischemia of the resected humeral head.

RESULTS

17 of 55 subjects (30.9%) were treated conservatively, 21 (38.2%) underwent open reduction internal fixation and 17 of 55 (30.9%) underwent arthroplasty. Of the 38 subjects treated conservatively or with ORIF, 20 (52.6%) completed 12 months of follow up and 14 (36.8%) 24 months of follow up. At 12 months follow up, two of 20 subjects (10%) and at 24 months 3 of 14 subjects (21.4%) developed avascular necrosis. At 12 months, the mean humerus/glenoid iodine ratio was 1.05 (standard deviation 0.24) in subjects with AVN compared to 0.91 (0.24) in those who did not. At 24 months, subjects with avascular necrosis had a mean humerus/glenoid iodine concentration ratio of 1.06 (0.17) compared to 0.924 (0.21) in those who did not. Of 17 arthroplasty subjects, 2 had severe ischemia and an iodine ratio of 1.08 (0.30); 5 had focal ischemia and a ratio of 1.00 (0.36); and 8 no ischemia and a ratio of 0.83 (0.08).

CONCLUSIONS

Quantifying iodine using dual energy CT in subjects with proximal humerus fractures is technically feasible. Preliminary data suggest higher humeral head iodine concentration may increase risk of avascular necrosis; however, future studies must enroll and follow enough subjects managed with open reduction internal fixation or conservatively for two or more years to provide statistically significant results. Trial Registrations NCT02170545 registered June 23, 2014, ClinicalTrials.gov.

Management of Posttraumatic Avascular Necrosis of the Proximal Humerus

The etiology of avascular necrosis (AVN) of the proximal humerus can be classified as idiopathic or posttraumatic, the latter being mainly due to proximal humerus fractures. Evidence suggests that posttraumatic AVN may require surgical intervention more often than idiopathic AVN of the proximal humerus. This article provides a comprehensive review of the management of posttraumatic AVN of the proximal humerus. Early stage AVN (stages 1 to 3) is commonly treated with nonoperative intervention or core decompression of the humeral head, whereas later stage disease (stages 4 and 5) may require hemiarthroplasty or total shoulder arthroplasty to restore function. [Orthopedics. 2021;44(6):367-375.].

Protective and Risk Factors for Humerus Head Necrosis After Proximal Humerus Fracture Treated with Internal Locking Plate

BACKGROUND

Proximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3-35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel's criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis.

METHODS

In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN.

RESULTS

HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer's classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN.

CONCLUSION

We conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing

BACKGROUND

The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures.

METHODS

We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months).

RESULTS

Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively.

CONCLUSIONS

Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.

Rate of avascular necrosis and time to surgery in proximal humerus fractures

PURPOSE

Avascular necrosis (AVN) of the humeral head is a devastating complication of proximal humeral fracture (PHF) that often results in long-term morbidity for the patient. Rates of AVN depend on the number of fracture fragments and are highly variable. The literature suggests that timely stable and anatomic reduction may decrease the rate at which AVN develops after PHF. To our knowledge, there is no literature published investigating a temporal relationship between the timing of PHF fixation and rates of AVN.

METHODS

Operative records of one orthopedic trauma surgeon were used to identify patients that underwent open reduction internal fixation for PHF at our institution between 2007 and 2012. Radiographs at presentation were reviewed and used to classify the fractures into two, three or four parts. Date and time of the initial radiograph were recorded as were the date and time of available intra-operative fluoroscopic images. The time from presentation radiograph to operative fixation was calculated (hours). Available follow-up plain films were then reviewed and evaluated for the presence or absence of humeral head AVN.

RESULTS

Time to surgery (less than or greater than 72 h) and patient age did not correlate with development of AVN after PHF (p > 0.26). Notably, the number of fracture fragments did influence the rate of AVN identified in patients with PHF (p = 0.002).

CONCLUSION

Early operative intervention does not appear to decrease the rate of development of avascular necrosis after PHF.

Surgical Management of Proximal Humeral Fractures: The Emerging Role of Reverse Total Shoulder Arthroplasty

Acute proximal humeral fractures are common injuries in elderly patients. These fractures can lead to significant pain and functional loss. Nonoperative treatment offers high rates of satisfactory function and pain relief in the majority of fractures, particularly in elderly patients. Open reduction and internal fixation, closed reduction and percutaneous pinning, and hemiarthroplasty are used for treating displaced proximal humeral fractures, depending on patient and fracture characteristics. Recently, reverse total shoulder arthroplasty has gained popularity for treatment of complex proximal humeral fractures due to a rapid recovery of active elevation and activities of daily living function. Although complications remain a concern, early results of reverse total shoulder arthroplasty for proximal humeral fractures have been promising. Future comparative outcome studies are needed to define the indications for reverse total shoulder arthroplasty instead of nonoperative and other operative options. Optimal treatment of proximal humeral fractures requires clinical judgment based on fracture characteristics, bone quality, patient factors, and surgeon experience with the array of available techniques. [Orthopedics. 2016; 39(3):e465-e473.].

Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures

BACKGROUND

Open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and anatomic or reverse total shoulder arthroplasty (TSA/RTSA) are surgical treatment options for proximal humeral fractures (PHFx). Little is known about comparative complication rates. We aimed to determine whether ORIF for PHFx has fewer 30-day complications than HA and TSA/RTSA and to define independent risk factors for 30-day complications.

METHODS

Patients who underwent ORIF, HA, or TSA/RTSA for PHFx between 2006 and 2013 were identified from the National Surgical Quality Improvement Program database. Potential patient and surgical risk factors and 30-day postoperative complications were extracted. Univariate and multivariate analyses were conducted.

RESULTS

We identified 1791 patients (1262 ORIF, 404 HA, and 125 TSA/RTSA). The overall complication rate was 13.0% in ORIF, 22.0% in HA, and 23.2% in TSA/RTSA (P < .001), driven primarily by rates of blood transfusion. Multivariate analyses demonstrated ORIF was an independent protective factor against minor complications (P = .009) and overall complications (P = .028) but not against major complications (P = .351). Risk factors for overall complications included preoperative sepsis (P < .001), higher American Society of Anesthesiologists Physical Status Classification (P < .001), dependent functional status (P = .002), transfusion of at least 5 units in the 72 hours before surgery (P = .002), longer operative time (P = .003), and a history of chronic obstructive pulmonary disease (P = .028).

CONCLUSIONS

After adjusting for patient factors, ORIF for PHFx remains an independent protective factor against overall complications and minor complications compared with HA and TSA/RTSA, primarily due to lower rates of blood transfusion. Patient comorbidities play a larger role than the procedure selected in predicting short-term complications.

Least Possible Fixation Techniques of 4-Part Valgus Impacted Fractures of the Proximal Humerus: A Systematic Review

The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. We systematically reviewed clinical studies assessing the benefits and harms of least possible fixation techniques (LPFT) for this unique fracture type. Such information would be potentially helpful in developing an evidence-based approach in the management of these complex injuries. We performed analytic searches of PubMed, Embase, Web of Science, Google Scholar and the Cochrane Library, restricting it to the years 1991-2014. Included studies had to describe outcomes and complications after primary osteosynthesis with any type of LPFT apart from plate-screws and intramedullary nailing. Eligibility criteria were also included English language, more than 5 cases, minimum follow up of one year and report of clinical outcome using at least one relevant score (Constant, Neer or ASES). Based on 292 database hits we identified 12 eligible studies including 190 four-part valgus impacted fractures in 188 patients. All eligible studies were case series composed of min 8 to max 45 patients per study. The gender distribution was 60% (112) female and 40% (76) male. The average age of the patients at the time of injury was 54.5 years. In 8/12 studies an open reduction was used for fracture fixation using different surgical techniques including KW, cerclage wires, cannulated screws and osteosutures. Closed reduction and percutaneous fixation was used in 4 studies. Mean follow-up time ranged from 24 to 69 months. A good functional outcome (constant score >80) was reported in 9/12 studies. The most common complication was avascular necrosis of the humeral head with an overall incidence of 11% (range, 0-26.3%). Total avascular necrosis (AVN) was found in 15/188 patients (7.9%) and was more common in percutaneous techniques and partial AVN in 6/188 (3.1%) being more common in open techniques. The overall re-operation rate was very low (3.7%). Insufficient study designs cannot provide definite treatment recommendations and quantitative data synthesis of outcome. In general, LPFT for 4-part VI fractures leads to satisfactory outcomes with low incidence of complications. A considerable risk of biases can be attributed to fracture classification, proper radiological control, mean age of patients, mixed types of fixation methods, nonage adjusted clinical scoring and small follow up periods. These factors are discussed in detail. Level of evidence: systematic review of literature (level IV) as most of the studies were level IV.

Outcomes of intramedullary nailing for acute proximal humerus fractures: a systematic review

Background

While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.

Materials and methods

Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means.

Results

Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively.

Conclusions

Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available.

Level of evidence

Level IV, Systematic review.

Post-traumatic osteonecrosis of the proximal humerus

Post-traumatic osteonecrosis of the proximal humerus represents a challenging problem to the surgeon. It is commonly seen following multi-fragmentary fractures of the proximal humerus which may affect the long-term functional recovery after such injuries. This review summarises the current evidence on risk factors, reasons why estimating its epidemiology is difficult, the vascular supply of the humeral head, classification, and management options.

Percutaneous Fixation of Proximal Humeral Fractures

Introduction

The percutaneous approach to proximal humeral fixation emphasizes minimum dissection with the goal of preserving vascularity of the articular segments and thereby decreasing the risk of osteonecrosis.

Step 1: Preoperative Planning

Perform preoperative imaging to assess fracture displacement and comminution in order to confirm that percutaneous treatment is appropriate.

Step 2: Closed Fracture Reduction

Attempt closed fracture reduction prior to incision.

Step 3: Surgical Approach for Humeral Head and Shaft Reduction

Obtain anatomic humeral head reduction, insert terminally threaded pins, and check pin placement fluoroscopically.

Step 4: Tuberosity Fracture Reduction and Fixation of the Tuberosity Fragments

Fix the tuberosity fracture(s).

Step 5: Wound Closure

Cut the pins below the skin and irrigate and close the wounds.

Step 6: Postoperative Rehabilitation

Begin passive shoulder motion after pin removal, and initiate active motion at six weeks after pin removal.

Results

The results of this technique in twenty-seven patients with an average age of 58.8 years (range, forty-two to seventy-six years) at the time of injury were reported previously⁶.

Indications

Contraindications

Pitfalls & Challenges

Clinical investigation for displaced proximal humeral fractures in the elderly: a randomized study of two surgical treatments: reverse total prosthetic replacement versus angular stable plate Philos (The DELPHI-trial)

BACKGROUND

Treatment for displaced proximal humeral fractures is still under debate. Few studies exist at the highest level of evidence. Although reversed total shoulder prosthesis has gained popularity and showed promising results in the treatment for proximal humeral fractures in the elderly patients, no randomized controlled trials exist to the authors' knowledge.

METHODS/DESIGN

This study is a randomized semi-blinded controlled multicenter trial designed according to the Consort statement and the recommendations given by the Cochrane reviewers for proximal humeral fractures. The study will investigate whether a reversed total shoulder prosthetic replacement gain better functional outcome compared to open reduction and internal fixation using an angular stable plate in displaced three- and four parts proximal humeral fractures after two and five years follow-up.Participants are aged 65-85 admitted in seven different hospitals with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2. The intervention group is surgical treatment using a reversed total shoulder prosthesis (Delta X-tend) compared to open reduction and internal fixation with an angular stable plate (Philos) and thread cerclage in the control group. 60 patients will be randomized to each group.The primary outcome is shoulder function (Constant score). Secondary outcomes will be patient self-assessment form (Oxford shoulder score), a quality of life questionnaire (15D score) and resource implications (cost-effectiveness). Follow-ups take place at 3, 6, 12 and 24 months, and five years. The trial design is semi-blinded with blinded physiotherapists performing the functional testing of patients at all follow-ups.Randomization to treatment groups is electronic online, by independent supervisor (web-CRF). The recruitment of patients started at January 1.st 2013. Inclusion of 120 patients during three years is expected.

DISCUSSION

This semiblinded trial include a high number of patients compared to existing randomized trials in this field. To our knowledge and according to ClinicalTrials.gov, this is the first study that compare these two treatments for a displaced proximal humeral fracture in elderly patients. This may provide important information to help the surgeon to decide the best treatment in the future.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01737060.

Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures

BACKGROUND

The purpose of this study was to report complication and reoperation rates following non-arthroplasty fixation of shoulder fractures determined on the basis of observational, population-based data from all inpatient admissions in California over an eleven-year period.

METHODS

Records from all inpatient hospital discharges and subsequent readmissions related to operative non-arthroplasty treatment of proximal humeral fractures were obtained for patients in California from December 1994 through December 2005. These admissions were evaluated to identify patient and hospital characteristics associated with short and intermediate-term complications (within and after ninety days, respectively) as well as reoperation rates. Procedures performed included open reduction and internal fixation in 9254 patients, closed reduction and internal fixation in 1903 patients, and internal fixation without reduction in 302 patients.

RESULTS

The short-term complications included mortality in 401 patients (3.5%), which was associated with a higher Charlson comorbidity index (odds ratio [OR] = 1.5, p < 0.001) and male sex (OR = 1.7, p < 0.001); and pulmonary embolism in sixty patients (0.5%), which was associated with male sex (OR = 2.2, p = 0.007) and patient age of seventy-five years or older (OR = 3.6, p = 0.001). Intermediate-term reoperations included conversion to hemiarthroplasty in 174 patients (1.5%); and conversion to total shoulder arthroplasty in eight patients (0.07%), which was associated with an age of fifty to sixty-four years (hazard ratio = 2.8, p = 0.007). Overall, an age of sixty-five years or older, male sex, residence in an area with an income in the lowest two quintiles, and the presence of preexisting comorbidities were associated with elevated risks of short-term complications but not of intermediate-term conversion to arthroplasty. The ninety-day revision rate was 5.3%.

CONCLUSIONS

Surgical fixation of proximal humeral fractures has a low complication and mortality profile. The data provided in this study can serve in counseling patients about risks associated with operative fixation of displaced proximal humeral fractures.

Accuracy and reliability testing of two methods to measure internal rotation of the glenohumeral joint

BACKGROUND

We compared accuracy and reliability of a traditional method of measurement (most cephalad vertebral spinous process that can be reached by a patient with the extended thumb) to estimates made with the shoulder in abduction to determine if there were differences between the two methods.

METHODS

Six physicians with fellowship training in sports medicine or shoulder surgery estimated measurements in 48 healthy volunteers. Three were randomly chosen to make estimates of both internal rotation measurements for each volunteer. An independent observer made objective measurements on lateral scoliosis films (spinous process method) or with a goniometer (abduction method). Examiners were blinded to objective measurements as well as to previous estimates.

RESULTS

Intraclass coefficients for interobserver reliability for the traditional method averaged 0.75, indicating good agreement among observers. The difference in vertebral level estimated by the examiner and the actual radiographic level averaged 1.8 levels. The intraclass coefficient for interobserver reliability for the abduction method averaged 0.81 for all examiners, indicating near-perfect agreement. Confidence intervals indicated that estimates were an average of 8° different from the objective goniometer measurements. Pearson correlation coefficients of intraobserver reliability for the abduction method averaged 0.94, indicating near-perfect agreement within observers. Confidence intervals demonstrated repeated estimates between 5° and 10° of the original.

CONCLUSIONS

Internal rotation estimates made with the shoulder abducted demonstrated interobserver reliability superior to that of spinous process estimates, and reproducibility was high. On the basis of this finding, we now take glenohumeral internal rotation measurements with the shoulder in abduction and use a goniometer to maximize accuracy and objectivity.

Biomechanical considerations for surgical stabilization of osteoporotic fractures

The incidence of osteoporotic fractures has been steadily rising along with the aging of the population. Surgical management of these fractures can be a challenge to orthopedic surgeons. Diminished bone mass and frequent comminution make fixation difficult. Advancements in implant design and fixation techniques have served to address these challenges and when properly applied, can improve overall outcome. The purpose of this review is to describe fixation challenges of common osteoporotic fractures and provide options for successful treatment.

Hemiarthroplasty for proximal humerus fractures

Proximal humerus fractures are common injuries that are increasing in incidence with the aging of the population. While nonoperative treatment of some fracture patterns results in clinical success, other, more displaced and comminuted fractures may require surgery to ensure a successful outcome. It is important to evaluate both patient and fracture characteristics in deciding upon the appropriate type of treatment. Every effort should be made to perform a humeral sparing procedure in younger patients. In the elderly, especially with more complex four-part fractures and fracture dislocations, hemiarthroplasty and reverse total shoulder arthroplasty are indicated to decrease complication rates and improve functional outcomes. In hemiarthroplasties, it is critical to achieve proper implant height and positioning of the tuberosities. For those patients or fractures in which the tuberosities are unlikely to heal or cannot be adequately reconstructed, reverse total shoulder arthroplasty should be considered.

Evaluation and management of proximal humerus fractures

Proximal humerus fractures are common injuries, especially among older osteoporotic women. Restoration of function requires a thorough understanding of the neurovascular, musculotendinous, and bony anatomy. This paper addresses the relevant anatomy and highlights various management options, including indication for arthroplasty. In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. In the case of displaced fractures, when surgical intervention may be pursued, numerous constructs have been investigated. Of these, the proximal humerus locking plate is the most widely used. Arthroplasty is generally reserved for comminuted 4-part fractures, head-split fractures, or fractures with significant underlying arthritic changes. Reverse total shoulder arthroplasty is reserved for patients with a deficient rotator cuff, or highly comminuted tuberosities.