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Han S, Reddy KI, Lanfermeijer ND, Frangie R, Ismaily SK, Gold JE, Lundberg HJ, Rodriguez-Quintana D. Impact of Prophylactic Cerclage Location on Femoral Fracture Propagation: A Biomechanical Study. J Orthop Trauma 2024; 38:491-496. [PMID: 39150300 DOI: 10.1097/bot.0000000000002864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVES Prophylactic cerclage cables are often placed intraoperatively about a fracture to prevent propagation. However, biomechanical data supporting optimal cable placement location are lacking. The objective of this study was to evaluate the impact of prophylactic cerclage placement location on the propagation of femoral shaft fractures. METHODS The diaphysis of 14 fresh-frozen cadaveric femora were included. Volumetric bone mineral density in the femoral shaft was obtained from quantitative computed tomography scans. For each specimen, a 5-mm longitudinal fracture was created proximally to simulate a pre-existing fracture. After reaming of the femoral canal, a 3 degrees tapered wedge was advanced with an MTS machine at 0.2 mm/s until failure. The tests were conducted with a CoCr cable placed at varying distances (5 mm, 10 mm, 15 mm, 20 mm, and cableless) from the distal tip of the initial fracture. A compression loadcell was used to measure the cable tension during the tests. The axial force, displacement, and cable tension were monitored for comparison between groups. RESULTS In the cableless group, the mean force needed to propagate the fracture was 1017.8 ± 450.3 N. With the addition of a cable at 5 mm below the fracture, the failure force nearly doubled to 1970.4 ± 801.1 N (P < 0.001). This also led to significant increases in stiffness (P = 0.006) and total work (P = 0.001) when compared with the control group. By contrast, in the 15 and 20 mm groups, there were no significant changes in the failure force, stiffness, and total work as compared with the control group (P > 0.05). CONCLUSIONS Propagation of femoral shaft fracture was effectively resisted when a prophylactic cable was placed within 5 mm from the initial fracture, whereas cables placed more than 10 mm below the initial fracture were not effective in preventing fracture propagation.
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Affiliation(s)
- Shuyang Han
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
| | - Kartik I Reddy
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
| | - Nicholas D Lanfermeijer
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
| | - Robert Frangie
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
| | - Sabir K Ismaily
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
| | - Jonathan E Gold
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
| | - Hannah J Lundberg
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - David Rodriguez-Quintana
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX; and
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2
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Mini D, Reynolds KJ, Taylor M. Assessing screw length impact on bone strain in proximal humerus fracture fixation via surrogate modelling. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024; 40:e3840. [PMID: 38866503 DOI: 10.1002/cnm.3840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
A high failure rate is associated with fracture plates in proximal humerus fractures. The causes of failure remain unclear due to the complexity of the problem including the number and position of the screws, their length and orientation in the space. Finite element (FE) analysis has been used for the analysis of plating of proximal humeral fractures, but due to computational costs is unable to fully explore all potential screw combinations. Surrogate modelling is a viable solution, having the potential to significantly reduce the computational cost whilst requiring a moderate number of training sets. This study aimed to develop adaptive neural network (ANN)-based surrogate models to predict the strain in the humeral bone as a result of changing the length of the screws. The ANN models were trained using data from FE simulations of a single humerus, and after defining the best training sample size, multiple and single-output models were developed. The best performing ANN model was used to predict all the possible screw length configurations. The ANN predictions were compared with the FE results of unseen data, showing a good correlation (R2 = 0.99) and low levels of error (RMSE = 0.51%-1.83% strain). The ANN predictions of all possible screw length configurations showed that the screw that provided the medial support was the most influential on the predicted strain. Overall, the ANN-based surrogate model accurately captured bone strains and has the potential to be used for more complex problems with a larger number of variables.
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Affiliation(s)
- Daniela Mini
- Medical Device Research Institute, College of Science and Engineering, Flinders University, South Australia, Australia
| | - Karen J Reynolds
- Medical Device Research Institute, College of Science and Engineering, Flinders University, South Australia, Australia
| | - Mark Taylor
- Medical Device Research Institute, College of Science and Engineering, Flinders University, South Australia, Australia
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Greenfield PT, Coble TJ, Bell JA, Calandruccio JH, Weller WJ. Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery. Orthop Clin North Am 2024; 55:355-362. [PMID: 38782507 DOI: 10.1016/j.ocl.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Fragility fractures as a result of osteoporosis, osteopenia, or vitamin D deficiency are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate management and treatment options. A thorough perioperative evaluation can identify causes of low bone mineral density allowing for initiation of appropriate therapy. Surgical treatment of these fractures can be difficult, and techniques should be employed to ensure stable fixation. It is important to understand the potential pitfalls associated with treatment of fragility fractures to prevent avoidable complications. Postoperative management is key to preventing future injuries in this unique patient population.
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Affiliation(s)
- Paul T Greenfield
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - Tori J Coble
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - Jared A Bell
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - James H Calandruccio
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - William J Weller
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA.
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4
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Zdero R, Brzozowski P, Schemitsch EH. Biomechanical design optimization of proximal humerus locked plates: A review. Injury 2024; 55:111247. [PMID: 38056059 DOI: 10.1016/j.injury.2023.111247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance. METHODS The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English. RESULTS The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed. CONCLUSIONS Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada.
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada; Division of Orthopaedic Surgery, Western University, London, ON, Canada
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5
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Brorson S. Who should care about the patient's next fracture? A treatment gap after shoulder fractures in the elderly. Acta Orthop 2023; 94:514-515. [PMID: 37830981 PMCID: PMC10574245 DOI: 10.2340/17453674.2023.21273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Stig Brorson
- Center for Evidence-Based Orthopedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Denmark.
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6
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Zhelev D, Hristov S, Zderic I, Ivanov S, Visscher L, Baltov A, Ribagin S, Stoffel K, Kralinger F, Winkler J, Richards RG, Varga P, Gueorguiev B. Treatment of Metaphyseal Defects in Plated Proximal Humerus Fractures with a New Augmentation Technique-A Biomechanical Cadaveric Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1604. [PMID: 37763723 PMCID: PMC10536689 DOI: 10.3390/medicina59091604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Unstable proximal humerus fractures (PHFs) with metaphyseal defects-weakening the osteosynthesis construct-are challenging to treat. A new augmentation technique of plated complex PHFs with metaphyseal defects was recently introduced in the clinical practice. This biomechanical study aimed to analyze the stability of plated unstable PHFs augmented via implementation of this technique versus no augmentation. Materials and Methods: Three-part AO/OTA 11-B1.1 unstable PHFs with metaphyseal defects were created in sixteen paired human cadaveric humeri (average donor age 76 years, range 66-92 years), pairwise assigned to two groups for locked plate fixation with identical implant configuration. In one of the groups, six-milliliter polymethylmethacrylate bone cement with medium viscosity (seven minutes after mixing) was placed manually through the lateral window in the defect of the humerus head after its anatomical reduction to the shaft and prior to the anatomical reduction of the greater tuberosity fragment. All specimens were tested biomechanically in a 25° adduction, applying progressively increasing cyclic loading at 2 Hz until failure. Interfragmentary movements were monitored by motion tracking and X-ray imaging. Results: Initial stiffness was not significantly different between the groups, p = 0.467. Varus deformation of the humerus head fragment, fracture displacement at the medial humerus head aspect, and proximal screw migration and cut-out were significantly smaller in the augmented group after 2000, 4000, 6000, 8000 and 10,000 cycles, p ≤ 0.019. Cycles to 5° varus deformation of the humerus head fragment-set as a clinically relevant failure criterion-and failure load were significantly higher in the augmented group, p = 0.018. Conclusions: From a biomechanical standpoint, augmentation with polymethylmethacrylate bone cement placed in the metaphyseal humerus head defect of plated unstable PHFs considerably enhances fixation stability and can reduce the risk of postoperative complications.
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Affiliation(s)
- Daniel Zhelev
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
- Department of Orthopedics and Traumatology, University Hospital for Active Treatment, 8018 Burgas, Bulgaria;
| | - Stoyan Hristov
- Department of Orthopedics and Traumatology, University Hospital for Active Treatment, 8018 Burgas, Bulgaria;
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Stoyan Ivanov
- Department of Orthopaedics and Traumatology, Medical University of Varna, 9002 Varna, Bulgaria;
| | - Luke Visscher
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
- School of Medicine, Queensland University of Technology, Brisbane 4000, Australia
| | - Asen Baltov
- Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine ‘N. I. Pirogov’, 1606 Sofia, Bulgaria;
| | - Simeon Ribagin
- Department of Health Pharmaceutical Care, Medical College, University ‘Prof. Dr. Asen Zlatarov’, 8010 Burgas, Bulgaria;
| | - Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Franz Kralinger
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria;
- Trauma and Sports Department, Ottakring Clinic, Teaching Hospital, Medical University of Vienna, 1160 Vienna, Austria
| | - Jörg Winkler
- Cantonal Hospital Graubuenden, 7000 Chur, Switzerland;
| | - R. Geoff Richards
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
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Lu KY, Tai TH, Liu YH, Chiang CJ, Loh EW, Wong CC, Wu JJ. Post-Operative Greater Tuberosity Resorption or Malreduction Is Associated with Poor Prognostic Outcomes in Patients with Proximal Humeral Fractures Treated Operatively-A Single-Center Retrospective Cohort Study. Diagnostics (Basel) 2023; 13:2789. [PMID: 37685327 PMCID: PMC10486750 DOI: 10.3390/diagnostics13172789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: Proximal humerus fractures can be a debilitating condition if not properly treated. These fracture patterns are varied and differ in every patient. Functional outcomes may be determined by the integrity of the shoulder girdle involving the rotator cuff insertion. The post-operative resorption or malreduction of the greater tuberosity (GT) is an important factor contributing to the poor functional outcome of a patient. Thus, we intend to evaluate the cause-and-effect relationship between GT complications and clinical prognosis and outcomes. (2) Methods: A single-center retrospective comparative study was performed to evaluate the functional outcomes of patients undergoing operative fixation for this injury. A total of 387 consecutive cases treated operatively from 2019-2021 were included for analysis. (3) Results: 94 cases fulfilled our criteria for analysis. A matched-group comparison of 19 patients each was performed to compare demographics, post-operative fracture characteristics and clinical outcomes. (4) Conclusions: The resorption or malreduction of the GT contributes greatly to the prognostic outcome in patients treated with open reduction and internal fixation (ORIF) surgery. In our demographic study, obesity is another contributing factor affecting the parameters of post-operative reduction in proximal humerus fractures. Appropriate surgical planning and post-operative multidisciplinary care must be taken into consideration to attain a satisfactory prognostic outcome.
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Affiliation(s)
- Kuan-Yu Lu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Ting-Han Tai
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Yu-Hsin Liu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Chang-Jung Chiang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - El-Wui Loh
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Center for Evidence-Based Health Care, Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei 11031, Taiwan
- Department of Medical Imaging, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Chin-Chean Wong
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei 11031, Taiwan
| | - Jeffrey J. Wu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
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Furuhata R, Tanji A, Oki S, Kamata Y. Influence of Proximal Humeral Cortical Bone Thickness on the Radiographic Outcome After Osteosynthesis of Proximal Humeral Fractures: Propensity Matching Score Analysis. Geriatr Orthop Surg Rehabil 2023; 14:21514593231198645. [PMID: 37645438 PMCID: PMC10460996 DOI: 10.1177/21514593231198645] [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: 06/09/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Osteoporosis can affect the surgical outcomes of proximal humeral fractures in older people. Recently, the cortical bone thickness of the proximal humerus on plain radiograph has been proposed to reflect local osteoporosis of the proximal humerus; however, its effect on the surgical outcome of proximal humeral fractures remains unclear. The purpose of this study is to investigate the influence of cortical bone thickness on postoperative radiographic outcomes after osteosynthesis for proximal humeral fractures. Materials and Methods We retrospectively identified 190 patients (≥50 years) who underwent osteosynthesis with an intramedullary nail or plate for proximal humeral fractures. The patients were categorized into 2 groups according to the cut-off value of an average proximal humerus cortical bone thickness of 6 mm on plain radiographs: patients with and without local osteoporosis. After propensity score matching, we compared the incidence of postoperative radiographic complications between the 2 groups. We also performed subgroup analyses of outcomes in a subgroup of patients who underwent intramedullary nailing and those who underwent plate fixation. Results Propensity score matching yielded 60 patients in each group. No significant difference in complication rates was observed between the 2 groups. However, in the intramedullary nailing subgroup, the incidence of reduction loss was significantly higher in patients with local osteoporosis than in those without local osteoporosis (51.7% vs 14.3%, P = .002). Discussion The proximal humeral cortical bone thickness had no significant effect on the overall radiographic outcome; however, reduction loss after intramedullary nailing was susceptible to local osteoporosis of the proximal humerus. Conclusion Our study suggests that plate fixation is advantageous in preventing postoperative reduction loss in patients with lower cortical bone thickness.
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Affiliation(s)
- Ryogo Furuhata
- Department of Orthopaedic Surgery,Ashikaga Red Cross Hospital, Ashikaga-shi, Japan
| | - Atsushi Tanji
- Department of Orthopaedic Surgery,Ashikaga Red Cross Hospital, Ashikaga-shi, Japan
| | - Satoshi Oki
- Department of Orthopaedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya-shi, Japan
| | - Yusaku Kamata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Meguro-ku, Japan
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Wang M, Wang X, Cai P, Guo S, Fu B. Locking plate fixation versus intramedullary nail fixation for the treatment of multifragmentary proximal humerus fractures (OTA/AO type 11C): a preliminary comparison of clinical efficacy. BMC Musculoskelet Disord 2023; 24:461. [PMID: 37277746 DOI: 10.1186/s12891-023-06567-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/23/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND This study aimed to compare the clinical efficacy of locking plate and intramedullary nail fixations in the treatment of patients with OTA/AO type 11C proximal humerus fractures. METHODS We retrospectively analyzed the data of patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures who underwent surgery at our institution from June 2012 to June 2017. Perioperative indicators, postoperative morphological parameters of the proximal humerus, and Constant-Murley scores were evaluated and compared. RESULTS Sixty-eight patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures were enrolled in this study. Overall, 35 patients underwent open reduction and plate screw internal fixation, and 33 patients underwent limited open reduction and locking of the proximal humerus with intramedullary nail internal fixation. The total cohort had a mean follow-up duration of 17.8 months. The mean operation time of the locking plate group was significantly longer than that of the intramedullary nail group (P < 0.05), while the mean bleeding volume was significantly higher in the locking plate group than that in the intramedullary nail group (P < 0.05). The initial neck-shaft angles, final neck-shaft angles, forward flexion ranges, or Constant-Murley scores did not show significant differences between the two groups (P > 0.05). Complications, including screw penetrations, acromion impingement syndrome, infection, and aseptic necrosis of the humeral head, occurred in 8 patients (8/35, 22.8%) in the locking plate group and 5 patients in the intramedullary nail group (5/33, 15.1%; including malunion and acromion impingement syndrome), with no significant difference between the groups (P > 0.05). CONCLUSIONS Similar satisfactory functional results can be achieved with locking plates and intramedullary nailing for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures, with no significant difference in the number of complications between these two techniques. However, intramedullary nailing has advantages over locking plates for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures in terms of operation time and bleeding volume.
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Affiliation(s)
- Minghui Wang
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Xiuhui Wang
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Pan Cai
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Shengyang Guo
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Beigang Fu
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China.
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10
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Wendler T, Fischer B, Schleifenbaum S, Theopold J, Hepp P. Dynamic biomechanical investigation of a novel sulcus bicipitalis plate in combination with a conventional locking plate for the treatment of complex proximal humerus fractures. Clin Biomech (Bristol, Avon) 2023; 105:105984. [PMID: 37156192 DOI: 10.1016/j.clinbiomech.2023.105984] [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: 01/20/2023] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Complex proximal humerus fractures place high demands on osteosynthetic treatment. In some cases, double plating has already been used to increase primary stability of the osteosynthesis. This approach was advanced in the present study by developing an additive plate for the sulcus bicipitalis. To demonstrate the superior primary stability of the newly developed plate osteosynthesis, a biomechanical comparison against a conventional locking plate with an additional calcar screw was performed. METHODS Ten pairs of cadaveric humeri were treated proximally with a locking plate (PENTA plate small fragment, INTERCUS). Each had a two-part fracture model with a fracture gap of 10 mm. All right humeri were treated with an additive novel plate that extends along the bicipital sulcus and encircles the lesser tuberosity proximally. First, the specimens were loaded sinusoidally at 250 N in 20° abduction for 5000 cycles. Afterwards quasi-static loading until failure was applied. FINDINGS The movement at the fracture gap due to the cyclic loading occurred mainly as rotation around the z-axis, corresponding to a tilt medially and distally. The double plate osteosynthesis reduces the rotation by approximately 39%. For all load cycles observed, except 5000 cycles, medial and distal rotation of the head was significantly reduced by the double plate. The failure loads showed no significant differences between the groups. INTERPRETATION In the tested scenario under cyclic loading, the novel double plate osteosynthesis showed a significant superiority of primary stability over the conventional treatment with one locking plate. Furthermore, the study showed the advantages of cyclic load application over quasi-static load application until failure.
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Affiliation(s)
- Toni Wendler
- ZESBO - Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany; Institute of Anatomy, Leipzig University, Leipzig, Germany.
| | - Benjamin Fischer
- ZESBO - Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany; Institute of Anatomy, Leipzig University, Leipzig, Germany
| | - Stefan Schleifenbaum
- ZESBO - Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany; Department of Orthopaedic, Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - Jan Theopold
- Department of Orthopaedic, Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
| | - Pierre Hepp
- ZESBO - Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany; Department of Orthopaedic, Trauma and Plastic Surgery, Leipzig University, Leipzig, Germany
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11
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Synek A, Ortner L, Pahr DH. Accuracy of osseointegrated screw-bone construct stiffness and peri-implant loading predicted by homogenized FE models relative to micro-FE models. J Mech Behav Biomed Mater 2023; 140:105740. [PMID: 36863197 DOI: 10.1016/j.jmbbm.2023.105740] [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: 12/21/2022] [Revised: 02/09/2023] [Accepted: 02/21/2023] [Indexed: 02/24/2023]
Abstract
Computational predictions of stiffness and peri-implant loading of screw-bone constructs are highly relevant to investigate and improve bone fracture fixations. Homogenized finite element (hFE) models have been used for this purpose in the past, but their accuracy has been questioned given the numerous simplifications, such as neglecting screw threads and modelling the trabecular bone structure as a continuum. This study aimed to investigate the accuracy of hFE models of an osseointegrated screw-bone construct when compared to micro-FE models considering the simplified screw geometry and different trabecular bone material models. Micro-FE and hFE models were created from 15 cylindrical bone samples with a virtually inserted, osseointegrated screw (fully bonded interface). Micro-FE models were created including the screw with threads (=reference models) and without threads to quantify the error due to screw geometry simplification. In the hFE models, the screws were modelled without threads and four different trabecular bone material models were used, including orthotropic and isotropic material derived from homogenization with kinematic uniform boundary conditions (KUBC), as well as from periodicity-compatible mixed uniform boundary conditions (PMUBC). Three load cases were simulated (pullout, shear in two directions) and errors in the construct stiffness and the volume average strain energy density (SED) in the peri-implant region were evaluated relative to the micro-FE model with a threaded screw. The pooled error caused by only omitting screw threads was low (max: 8.0%) compared to the pooled error additionally including homogenized trabecular bone material (max: 92.2%). Stiffness was predicted most accurately using PMUBC-derived orthotropic material (error: -0.7 ± 8.0%) and least accurately using KUBC-derived isotropic material (error: +23.1 ± 24.4%). Peri-implant SED averages were generally well correlated (R2 ≥ 0.76), but slightly over- or underestimated by the hFE models and SED distributions were qualitatively different between hFE and micro-FE models. This study suggests that osseointegrated screw-bone construct stiffness can be predicted accurately using hFE models when compared to micro-FE models and that volume average peri-implant SEDs are well correlated. However, the hFE models are highly sensitive to the choice of trabecular bone material properties. PMUBC-derived isotropic material properties represented the best trade-off between model accuracy and complexity in this study.
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Affiliation(s)
- Alexander Synek
- Institute of Lightweight Design and Structural Biomechanics, TU Wien, Austria.
| | - Lukas Ortner
- Institute of Lightweight Design and Structural Biomechanics, TU Wien, Austria
| | - Dieter H Pahr
- Institute of Lightweight Design and Structural Biomechanics, TU Wien, Austria; Division Biomechanics, Karl Landsteiner University of Health Sciences, Austria
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Mys K, Visscher L, van Knegsel KP, Gehweiler D, Pastor T, Bashardoust A, Knill AS, Danker C, Dauwe J, Mechkarska R, Raykov G, Karwacki GM, Knobe M, Gueorguiev B, Windolf M, Lambert S, Nijs S, Varga P. Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020370. [PMID: 36837571 PMCID: PMC9966327 DOI: 10.3390/medicina59020370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.
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Affiliation(s)
- Karen Mys
- AO Research Institute Davos, 7270 Davos, Switzerland
| | - Luke Visscher
- AO Research Institute Davos, 7270 Davos, Switzerland
- Royal Brisbane and Women’s Hospital, 4029 Brisbane, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, 4000 Brisbane, Australia
| | - Kenneth Petrus van Knegsel
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | | | - Torsten Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | | | | | | | - Jan Dauwe
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rayna Mechkarska
- AO Research Institute Davos, 7270 Davos, Switzerland
- University Multiprofile Hospital for Active Treatment and Emergency Medicine “N. I. Pirogov”, 1606 Sofia, Bulgaria
| | - Georgi Raykov
- AO Research Institute Davos, 7270 Davos, Switzerland
- Medical University of Varna ‘‘Prof. Dr. Paraskev Stoyanov’’, 9002 Varna, Bulgaria
| | - Grzegorz Marek Karwacki
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | | | | | - Simon Lambert
- University College London Hospital, London NW1 2BU, UK
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland
- Correspondence:
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13
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Bue M, Bright E, Thillemann TM, Mosegaard SB, Hansen TB, Klebe T, Mechlenburg I, Stilling M. Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up. J Shoulder Elbow Surg 2023; 32:292-301. [PMID: 35998782 DOI: 10.1016/j.jse.2022.07.008] [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: 02/20/2022] [Revised: 06/17/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this prospective study was to investigate bone mineral density (BMD) changes in the proximal humerus of the shoulder during a healing period of 12 months after displaced 3- or 4-part proximal humerus fractures treated with open reduction and internal fixation (ORIF) with an anatomic angular stable locking plate and the influence on fracture healing and functional outcomes. METHODS In a prospective multicenter study, 36 patients (29F and 7M, age range: 38-83) with unilateral displaced 3- or 4-part proximal humerus fractures were included for ORIF. Dual-energy x-ray absorptiometry for osteoporosis status was employed. Postoperative and 6-week, 3-, 6-, and 12-month shoulder radiographs and dual-energy x-ray absorptiometry of the shoulder with BMD measures in 4 templated regions of interest (ROIs) were performed. Functional outcomes, Western Ontario Osteoarthritis of the Shoulder index, Constant score, visual analog scale pain (VAS), and 36-Item Short Form Survey, were collected. RESULTS A total of 17 of 36 patients had osteoporosis. We found no differences in BMD changes, functional outcomes, radiology, or need for revision surgery between the osteoporosis and nonosteoporosis groups. The BMD values gradually declined from baseline to 3-month follow-up in all 4 ROIs of the operated shoulders. All 4 ROIs in the operated shoulder presented with a reduction in BMD at 3, 6, and 12 months compared with baseline, whereas no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in Constant score from 3 to 12 months, but a decrease in domains of the 36-Item Short Form Survey from preinjury to 12 months (physical functioning, general health, and bodily pain). Preinjury and 12-month Western Ontario Osteoarthritis of the Shoulder index, VAS pain at rest, and VAS pain at activity were comparable. CONCLUSION BMD changes appeared swiftly in the proximal humerus, after the treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis of the humerus. Shoulder function was restored to preinjury levels for most of the patients. Osteoporosis may not be regarded as a contraindication for the treatment of displaced 3- or 4-part fractures with ORIF.
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Affiliation(s)
- Mats Bue
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Elisabeth Bright
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sebastian Breddam Mosegaard
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark
| | - Torben Bæk Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark
| | - Thomas Klebe
- Department of Orthopaedic Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Inger Mechlenburg
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Maiken Stilling
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark.
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Continuous Shoulder Activity Tracking after Open Reduction and Internal Fixation of Proximal Humerus Fractures. Bioengineering (Basel) 2023; 10:bioengineering10020128. [PMID: 36829622 PMCID: PMC9952737 DOI: 10.3390/bioengineering10020128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/06/2023] [Accepted: 01/08/2023] [Indexed: 01/19/2023] Open
Abstract
Postoperative shoulder activity after proximal humerus fracture treatment could influence the outcomes of osteosynthesis and may depend on the rehabilitation protocol. This multi-centric prospective study aimed at evaluating the feasibility of continuous shoulder activity monitoring over the first six postoperative weeks, investigating potential differences between two different rehabilitation protocols. Shoulder activity was assessed with pairs of accelerometer-based trackers during the first six postoperative weeks in thirteen elderly patients having a complex proximal humerus fracture treated with a locking plate. Shoulder angles and elevation events were evaluated over time and compared between the two centers utilizing different standard rehabilitation protocols. The overall mean shoulder angle ranged from 11° to 23°, and the number of daily elevation events was between 547 and 5756. Average angles showed longitudinal change <5° over 31 ± 10 days. The number of events increased by 300% on average. Results of the two clinics exhibited no characteristic differences for shoulder angle, but the number of events increased only for the site utilizing immediate mobilization. In addition to considerable inter-patient variation, not the mean shoulder angle but the number of elevations events increased markedly over time. Differences between the two sites in number of daily events may be associated with the different rehabilitation protocols.
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Tarallo L, Micheloni GM, Giorgini A, Lombardi M, Limone B, Catani F, Porcellini G. Anatomically reduced fixation should always be considered when treating B and C proximal epiphyseal humeral fractures. J Orthop Traumatol 2022; 23:51. [PMID: 36334166 PMCID: PMC9637075 DOI: 10.1186/s10195-022-00668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
Background Proximal humeral fractures are commonly observed in elderly patients. Management of these injuries is controversial. Literature comparing locking plate fixation, arthroplasty, and conservative treatments show no clear advantages for any of these management strategies. Thus far, no study has considered anatomically reduced fractures obtained after locking plate treatment. To clarify the best surgical procedure in middle-aged patients, we considered outcomes and major complications leading to surgical revision following an anatomically reduced fracture fixed with locking plate and reverse shoulder arthroplasty (RSA) in the treatment of type B/C fractures in patients between 50 and 75 years of age. Methods This is a retrospective study including 59 patients between 50 and 75 years of age with type B/C proximal humeral fracture treated with RSA or with locking plate fixation (resulting in an anatomical reduction) between January 2010 and December 2018. Preoperative radiographs and computed tomography (CT) were evaluated in all patients. Clinical and radiologic follow-up was performed using range of motion (ROM), the Constant–Murley Score (CMS), the Oxford Shoulder Score (OSS), the Simple Shoulder Test (SST), the Subjective Shoulder Value (SSV), and visual analog scale (VAS). Major complications were considered. Results In the plate fixation group, ROM, CMS, SST, and VAS were higher than in the RSA group. Lower complication rates compared with the literature were observed in both groups. Anatomically reduced fracture fixed with plate and screw could outperform RSA in terms of outcome. In second-level centers where traumatology is performed by surgeons with great expertise in upper limb trauma, the choice between plate fixation and reverse arthroplasty should be made during surgery. Conclusion Anatomically reduced fractures showed better outcomes compared with RSA in type B/C fractures. Surgeons should always try to perform a reduction of the fracture in order to understand if a plate fixation could be feasible. If it is impossible to perform an anatomical reduction, we suggest to consider RSA. This is a retrospective observational study.
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Affiliation(s)
- Luigi Tarallo
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Gian Mario Micheloni
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Andrea Giorgini
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Martina Lombardi
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Beatrice Limone
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Fabio Catani
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Giuseppe Porcellini
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
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16
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Lian YS, Huang CH, Chuang MY. Catastrophic failure of a titanium locking plate in a proximal humeral fracture: case report and literature review. BMC Musculoskelet Disord 2022; 23:957. [PMCID: PMC9636662 DOI: 10.1186/s12891-022-05931-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Background Angular stable locking plates have shown good clinical results in treating proximal humeral fractures, but complications are not uncommon. This study reported a rare case of catastrophic failure of a titanium locking plate. A retrieval analysis of the implants was performed using an optic microscope and a scanning electron microscope. Case presentation A 69-year-old male reported a right proximal humeral fracture at the surgical neck and was treated by open reduction and internal fixation with a locking plate system. Ninety-six days after surgery, the patient came to clinic for acute local pain over the shoulder without any trauma. The radiographs showed a complete breakage of the implant accompanying displaced fracture. Revision surgery was performed to restabilize the fracture with a longer locking plate. The follow-up radiographs at 9 months showed complete union of the bone fracture. Conclusions From the retrieval analysis, repetitive torsion loads on the vulnerable area of the implant are assumed to cause this catastrophic event. It is recommended that adequate activity restriction, such as reaching, be undertaken to avoid this rare complication. Current study also provides contributive information for the modification of plate design and pre-operative planning for device configuration to improve the success rate of locking plate fixation.
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Affiliation(s)
- Yan-Shiang Lian
- grid.413593.90000 0004 0573 007XDepartment of Orthopaedic Surgery, MacKay Memorial Hospital, 10449 Taipei, Taiwan
| | - Chang-Hung Huang
- grid.413593.90000 0004 0573 007XDepartment of Medical Research, Biomechanics Research Laboratory, MacKay Memorial Hospital, 25160 New Taipei City, Taiwan ,grid.260539.b0000 0001 2059 7017School of Dentistry, National Yang Ming Chiao Tung University, 11221 Taipei, Taiwan
| | - Min-Yao Chuang
- grid.413593.90000 0004 0573 007XDepartment of Orthopaedic Surgery, MacKay Memorial Hospital, 10449 Taipei, Taiwan ,grid.260539.b0000 0001 2059 7017Department of Physical Therapy and Assistive Technology, National Yang Ming Chiao Tung University, 11221 Taipei, Taiwan
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17
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Mischler D, Schader JF, Dauwe J, Tenisch L, Gueorguiev B, Windolf M, Varga P. Locking Plates With Computationally Enhanced Screw Trajectories Provide Superior Biomechanical Fixation Stability of Complex Proximal Humerus Fractures. Front Bioeng Biotechnol 2022; 10:919721. [PMID: 35814016 PMCID: PMC9260250 DOI: 10.3389/fbioe.2022.919721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
Joint-preserving surgical treatment of complex unstable proximal humerus fractures remains challenging, with high failure rates even following state-of-the-art locked plating. Enhancement of implants could help improve outcomes. By overcoming limitations of conventional biomechanical testing, finite element (FE) analysis enables design optimization but requires stringent validation. This study aimed to computationally enhance the design of an existing locking plate to provide superior fixation stability and evaluate the benefit experimentally in a matched-pair fashion. Further aims were the evaluation of instrumentation accuracy and its potential influence on the specimen-specific predictive ability of FE. Screw trajectories of an existing commercial plate were adjusted to reduce the predicted cyclic cut-out failure risk and define the enhanced (EH) implant design based on results of a previous parametric FE study using 19 left proximal humerus models (Set A). Superiority of EH versus the original (OG) design was tested using nine pairs of human proximal humeri (N = 18, Set B). Specimen-specific CT-based virtual preoperative planning defined osteotomies replicating a complex 3-part fracture and fixation with a locking plate using six screws. Bone specimens were prepared, osteotomized and instrumented according to the preoperative plan via a standardized procedure utilizing 3D-printed guides. Cut-out failure of OG and EH implant designs was compared in paired groups with both FE analysis and cyclic biomechanical testing. The computationally enhanced implant configuration achieved significantly more cycles to cut-out failure compared to the standard OG design (p < 0.01), confirming the significantly lower peri-implant bone strain predicted by FE for the EH versus OG groups (p < 0.001). The magnitude of instrumentation inaccuracies was small but had a significant effect on the predicted failure risk (p < 0.01). The sample-specific FE predictions strongly correlated with the experimental results (R2 = 0.70) when incorporating instrumentation inaccuracies. These findings demonstrate the power and validity of FE simulations in improving implant designs towards superior fixation stability of proximal humerus fractures. Computational optimization could be performed involving further implant features and help decrease failure rates. The results underline the importance of accurate surgical execution of implant fixations and the need for high consistency in validation studies.
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Affiliation(s)
| | | | - Jan Dauwe
- AO Research Institute Davos, Davos, Switzerland
- Department of Trauma Surgery, UZ Leuven, Leuven, Belgium
| | | | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
- *Correspondence: Peter Varga,
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18
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Schader JF, Mischler D, Dauwe J, Richards RG, Gueorguiev B, Varga P. One size may not fit all: patient-specific computational optimization of locking plates for improved proximal humerus fracture fixation. J Shoulder Elbow Surg 2022; 31:192-200. [PMID: 34298147 DOI: 10.1016/j.jse.2021.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/04/2021] [Accepted: 06/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal treatment options for proximal humerus fractures (PHFs) are still debated because of persisting high fixation failure rates experienced with locking plates. Optimization of the implants and development of patient-specific designs may help improve the primary fixation stability of PHFs and reduce the rate of mechanical failures. Optimizing the screw orientations in locking plates has shown promising results; however, the potential benefit of subject-specific designs has not been explored yet. The purpose of this study was to evaluate by means of finite element (FE) analyses whether subject-specific optimization of the screw orientations in a fixed-angle locking plate can reduce the predicted cutout failure risk in unstable 3-part fractures. METHODS FE models of 19 low-density proximal humeri were generated from high-resolution computed tomographic images using a previously developed and validated computational osteosynthesis framework. The specimens were virtually osteotomized to simulate unstable malreduced 3-part fractures and fixed with the PHILOS plates using 6 proximal locking screws. The average principal compressive strain in cylindrical bone regions around the screw tips-a biomechanically validated surrogate for the risk of cyclic screw cutout failure-was defined as the main outcome measure. The angles of the 6 proximal locking screws were optimized via parametric analysis for each humerus individually, resulting in subject-specific screw orientations (SSO). The average peri-implant strains of the SSO were statistically compared with the previously reported cohort-specific (CSO) and original PHILOS screw orientations (PSO) for females vs. males. RESULTS The optimized SSO significantly reduced the peri-screw bone strain vs. CSO (6.8% ± 4.0%, P = .006) and PSO (25.24% ± 7.93%, P < .001), indicating lower cutout risk for subject-specific configurations. The benefits of SSO vs. PSO were significantly higher for women than men. CONCLUSION The findings of this study suggest that subject-specific optimization of the locking screw orientations could lead to lower cutout risk and improved PHF fixation. These computer simulation results require biomechanical and clinical corroboration. Further studies are needed to evaluate whether the potential benefit in stability could justify the increased efforts related to implementation of individualized implants. Nevertheless, computational exploration of the biomechanical factors influencing the outcome of fracture fixations could help better understand the fixation failures and reduce their incidence.
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Affiliation(s)
| | | | - Jan Dauwe
- AO Research Institute Davos, Davos, Switzerland; Department of Trauma Surgery, UZ Leuven, Leuven, Belgium
| | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland.
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19
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Zhang X, Zhu CX, He JQ, Hu YC, Sun J. Correlation of CT Values and Bone Mineral Density in Elderly Chinese Patients with Proximal Humeral Fractures. Orthop Surg 2021; 13:2271-2279. [PMID: 34693649 PMCID: PMC8654650 DOI: 10.1111/os.13145] [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: 12/28/2020] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022] Open
Abstract
Objective To investigate the correlation between computed tomography (CT) values and bone mineral density (BMD) in elderly Chinese patients with proximal humeral fractures. Methods This was a single‐center retrospective study involving 166 elderly patients with proximal humeral fractures between January and June 2015 in our hospital. Following the inclusion and exclusion criteria, 89 patients were finally enrolled in this study. The spiral CT scanning was performed on these patients, and the CT images were obtained by using MIMICS software. The CT values in axial, coronal, and sagittal images of healthy proximal humeri were measured using a circular region of interest (ROI) by Image J. The bone mineral density (BMD) of the lumbar spine and femoral neck was measured using dual‐energy X‐ray absorptiometry (DXA). Spearman rank correlation methods were used for analysis of the association between the proximal humerus average CT value (CTMean) and the lumbar spine as well as femoral neck BMD in patients with proximal humeral fractures, or osteoporotic patients. Results Among the included 89 patients, there were 26 males and 63 females, 69% and 84% of whom were diagnosed with osteoporosis, respectively. The lumbar spine and femoral neck BMD and the CTMean of the proximal humerus were higher in males than females with proximal humeral fractures (P < 0.05). This gender difference was also found in the osteoporotic patient population (P < 0.05). The Spearman rank correlation method showed that the lumbar spine and femoral neck BMD was closely related to the proximal humeral CTMean in males (r = 0.877, P = 0.000; r = 0.832, P = 0.000; respectively) and females (r = 0.806, P = 0.000; r = 0.616, P = 0.000; respectively) with proximal humeral fractures, as well as osteoporotic male (r = 0.745, P = 0.000; r = 0.575, P = 0.000; respectively) and female (r = 0.613, P = 0.000; r = 0.629, P = 0.000; respectively) patients. Conclusions The CT value of the proximal humerus is a rapid and accurate method by which bone quality can be assessed in elderly patients with proximal humeral fractures. Moreover, the CT value of the proximal humerus is an alternative measurement of BMD that can guide surgeons in selecting the appropriate internal fixation material.
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Affiliation(s)
- Xi Zhang
- Department of Traumatics Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Chun-Xia Zhu
- Department of Ultrasounds, Tianjin Hospital, Tianjin, China
| | - Jin-Quan He
- Department of Traumatics Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Yong-Cheng Hu
- Department of Traumatics Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Jie Sun
- Department of Traumatics Orthopaedics, Tianjin Hospital, Tianjin, China
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20
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Michel PA, Katthagen JC, Schliemann B, Wilkens S, Frank A, Heilmann LF, Dyrna F, Raschke MJ. Biomechanical Value of a Protective Proximal Humeral Cerclage in Reverse Total Shoulder Arthroplasty. J Clin Med 2021; 10:jcm10194600. [PMID: 34640617 PMCID: PMC8509515 DOI: 10.3390/jcm10194600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/26/2021] [Accepted: 10/03/2021] [Indexed: 11/16/2022] Open
Abstract
Reverse shoulder arthroplasty (RSA) is a commonly performed salvage procedure for failed proximal humeral fracture fixation. The rate of intraoperative periprosthetic fractures is higher compared to primary RSA. The goal of this study was to investigate the biomechanical value of a protective cerclage during stem impaction in a revision surgery setting. Twenty-eight fresh-frozen human humeri were used to assess different configurations for steel wire and FiberTape cerclages. A custom-built biomechanical test setup simulated the mallet strikes during the stem impaction process with the Univers Revers prothesis stem. The mallet energy until the occurrence of a first crack was not different between groups. The total energy until progression of the fracture distally to the cerclage was significantly higher in the cerclage groups compared to the native humerus (9.5 J vs. 3.5 J, respectively; p = 0.0125). There was no difference between the steel wire and FiberTape groups (11.4 J vs. 8.6 J, respectively; p = 0.2695). All fractures were located at the concave side of the stem at the metaphyseal calcar region. This study demonstrates that a protective cerclage can successfully delay the occurrence of a fracture during stem impaction in reverse shoulder arthroplasty. A FiberTape cerclage is biomechanically equally efficient compared to a steel wire cerclage.
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Femoral neck fractures: Key points to consider for fixation or replacement a narrative review of recent literature. Injury 2021; 54 Suppl 1:S70-S77. [PMID: 34615597 DOI: 10.1016/j.injury.2021.09.024] [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: 04/23/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Femoral neck fractures (FNF) are frequent injuries and not rarely complicated by non-union, implant failure, and avascular necrosis. Some of these fractures represent a dilemma for trauma surgeons. Which fracture should be fixed? Which replaced with a prosthesis? How? The aim of this narrative review is to investigate the literature in order to provide the most updated and evidence-based knowledge about FNF' treatment. MATERIALS AND METHODS A literature research has been performed to find the essential key points to consider when dealing with FNF and their treatment. The most representative papers and the new meta-analysis were matched with authors' experience to give a concise but comprehensive view of the problem. Timing, age, comorbidities, vascularization of the femoral head, displacement, instability, comminution of the fracture, bone quality, and surgeon experience seem to be the major topics to consider in the decision making. We then focus on the optimal fixation or replacement as suggested by the literature. RESULTS Age is the main independent factor to consider. Timing seems essential in the elderly population to reduce mortality and important in the younger patients to reduce complications. Vascular supply should be always considered. Displacement, instability, and comminution of the fracture are negative prognostic factors for fixation as well as, theoretically, bone quality. In the elderly hip replacement is mostly indicated. A stable and solid fixation is mandatory to allow early mobilization. Sliding Hip Screws (SHS) seem preferable to cannulated screws for displaced/unstable (Pauwels II-III, posterior comminution) and basicervical fracture patterns or in smokers. There is a tendency toward Total Hip Arthroplasty (THA) also in the elderly if the patient is an indipendent ambulator without severe comorbidities. Dual mobility cups are gaining popularity in THA for FNF. CONCLUSIONS FNF are frequent injuries and represent, in some cases, a dilemma for the trauma surgeon. Age, timing, comorbidities, bone quality, femoral head vascularization, fracture displacement, intrinsic instability, and comminution as surgeon experience should be carefully evaluated before surgery. A case-to-case analysis of the patient-related factors helps the surgeon to make the right choice and reduce the well-known complications.
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Abstract
PURPOSE OF REVIEW Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures. RECENT FINDINGS There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.
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Affiliation(s)
- Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA.
| | | | - Hwabok Wee
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
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Morphometric Characterization of the Collum Chirurgicum. JOURNAL OF BASIC AND CLINICAL HEALTH SCIENCES 2021. [DOI: 10.30621/jbachs.856197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Nail Versus Plate: A Biomechanical Comparison of a Locking Plate Versus an Intramedullary Nail With an Angular Stable Locking System in a Shoulder Simulator With Active Muscle Forces Using a Two-Part Fracture Model. J Orthop Trauma 2021; 35:e71-e76. [PMID: 33079835 DOI: 10.1097/bot.0000000000001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare a locking compression plate versus an intramedullary nail with an angular stable locking system (ASLS) using a 2-part fracture model in a shoulder test bench. METHODS Twelve fresh frozen humeri were used for biomechanical testing in a shoulder simulator. A 2-part fracture model, with and without medial cortical support, was used to compare the locking plate and a nail with an ASLS. The varus impaction, varus per cycle motion, tilt, and tilt per cycle were analyzed. RESULTS No significant differences for the resulting forces in the glenoid fossa were evaluated. The stable fracture model showed no significant differences for the 2 groups. The median varus impaction was -0.96 degrees (range -0.55 to -4.26 degrees) in the plate group and 0.5 degrees (range -3.06 to 0.98 degrees) in the nail group, after 500 cycles of cyclic loading in the unstable fracture model. The plate group showed a significantly higher median varus impaction per cycle motion and median varus impaction at the 200th, 300th, and 400th cycle of physiological loading. CONCLUSIONS The intramedullary nail with the ASLS could be an alternative for patients suffering from osteoporosis and comorbidities.
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Taskesen A, Göçer A, Uzel K, Yaradılmış YU. Effect of Osteoporosis on Proximal Humerus Fractures. Geriatr Orthop Surg Rehabil 2021; 11:2151459320985399. [PMID: 33489429 PMCID: PMC7768827 DOI: 10.1177/2151459320985399] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/19/2020] [Accepted: 12/02/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction: Proximal humerus fractures (PHF) constitute the majority of the most common osteoporotic fractures. Bone density measurements can affect treatment methods and outcomes. This study was aimed to investigate the effect of osteoporosis values, measured from direct radiographs, on fracture type, surgical outcomes. Methods: 248 patients over 50 years of age who presented to Mersin City Hospital between 2017 and 2020 with proximal humeral fractures were retrospectively evaluated. The age and gender of the patients and the fracture types were evaluated according to the AO classification system from the direct radiographs obtained at the time of admission were recorded. The Tingart cortical thickness and deltoid tuberosity index (DTI) measurements were used to assess osteoporosis status in all patients. Postoperative and follow-up radiographs of 45 patients, treated with fixed-angle proximal humeral locking plate, were evaluated for radiographic results and their correlations with osteoporosis measurements were examined. Results: According to the demographic characteristics of the patients, 171 patients were female and 77 patients were male (F/M: 3/1), and mean age was 69.2 ± 11.66 (50-95). Considering the bone quality parameters in all patients, the mean Tingart value was 5.8 ± 1.6 mm and the mean DTI was 1.43 ± 0.17, where there was a correlation between the Tingart value and DTI (r = 0.810 and p < 0.001). Although there was a statistically significant relationship between the osteoporosis parameters and age and gender (p < 0.001 and p = 0.023, respectively), main AO fracture types were not related to osteoporosis (p < 0.05). In the operated group (n = 48, 19%), 19 patients (42%) showed poor outcomes, which were not associated with age and osteoporosis parameters. Conclusion: This study was concluded that osteoporosis parameters differ between genders and age groups in patients with PHF, however osteoporosis is not the main factor affecting the fracture type and surgical outcomes.
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Affiliation(s)
- Anil Taskesen
- Department of Orthopaedics and Traumatology, Mersin City Education and Research Hospital, Mersin, Turkey
| | - Ali Göçer
- Department of Orthopaedics and Traumatology, Mersin City Education and Research Hospital, Mersin, Turkey
| | - Kadir Uzel
- Department of Orthopaedics and Traumatology, Mersin City Education and Research Hospital, Mersin, Turkey
| | - Yüksel Uğur Yaradılmış
- Department of Orthopaedics and Traumatology, Keçiören Education and Research Hospital, Ankara, Turkey
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Feissli S, Audigé L, Steinitz A, Müller AM, Rikli D. Treatment options for proximal humeral fractures in the older adults and their implication on personal independence. Arch Orthop Trauma Surg 2020; 140:1971-1976. [PMID: 32350602 DOI: 10.1007/s00402-020-03452-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND No consensus exists on the optimal treatment of proximal humeral fractures (PHFx). Uncertainty about surgical treatment in the older adults using locking plates (e.g., PHILOS) has emerged, due to a high number of complications. This study aimed to assess the impact of non-operative versus operative treatment of a PHFx on the level of self-dependence in our older population. METHODS We included patients aged over 65 years with some level of self-dependence, treated at our hospital between 5/2011 and 4/2013 for isolated PHFx of AO subtypes A2, A3, and B1 for which either non-operative or surgical treatment using a PHILOS plate had been applied. The patients were questioned, examined, or interviewed via phone; AO fracture patterns and treatment were documented as well as level of self-dependence, complications, constant score (CSM), subjective shoulder value (SSV), quality of life (EQ-5D), and shoulder pain and disability index (SPADI). RESULTS Patients with PHFx of AO subtypes A2, A3, or B1 that were either treated non-operative (n = 50) or operative by insertion of the PHILOS plate (n = 63) were included. Operative-treated patients were 3.3 times as likely to lose some level of independence (95% CI 0.39-28, p = 0.271). Shoulder motion, strength, and functional outcomes tended to be lower in operative-treated patients, with adjusted differences of, - 11 CMS points (95% CI - 23 to 2), - 9 SPADI points (95% CI - 18 to 0), and - 6% in SSV (95% CI - 17 to 5). Quality-of-life EQ-5D utility index was similar in both groups (mean - 0.04; 95% CI - 0.18 to 0.10). CONCLUSION In our study population, non-operatively treated older adults with an AO type A2, A3, B1 fracture of the proximal humerus tended to have a high chance to return to their premorbid level of independence, compared to patients treated with a locking plate. A change in the treatment algorithm for these PHFx may be carefully considered and further investigated in clinical practice.
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Affiliation(s)
- Sandra Feissli
- Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Laurent Audigé
- Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Research and Development Department, Schulthess Clinic, Zurich, Switzerland.,Institute of Clinical Epidemiology and Biostatistics, University Hospital of Basel, Basel, Switzerland
| | - Amir Steinitz
- Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Andreas M Müller
- Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Daniel Rikli
- Department of Orthopaedic Surgery and Traumatology, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
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Kim H, Lee W, Choi S, Kholinne E, Lee E, Alzahrani WM, Koh KH, Jeon IH, Kim S. Role of Additional Inferomedial Supporting Screws in Osteoporotic 3-Part Proximal Humerus Fracture: Finite Element Analysis. Geriatr Orthop Surg Rehabil 2020; 11:2151459320956958. [PMID: 33224551 PMCID: PMC7649924 DOI: 10.1177/2151459320956958] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/08/2020] [Accepted: 08/18/2020] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | - Erica Kholinne
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Orthopedic Surgery, St. Carolus Hospital, Jakarta, Indonesia
| | - Euisop Lee
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wael Mohammed Alzahrani
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Orthopaedic Surgery, Najran University Hospital, Najran, Saudi Arabia
| | - Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shinseok Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Mischler D, Windolf M, Gueorguiev B, Nijs S, Varga P. Computational optimisation of screw orientations for improved locking plate fixation of proximal humerus fractures. J Orthop Translat 2020. [DOI: 10.1016/j.jot.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Sandmann G, Ateschrang A, Freude T, Stöckle U, Schmölz W, Konrads C, Döbele S. Dynamic locking screws in proximal humeral plate osteosynthesis demonstrate superior fixation properties: a biomechanical study. J Exp Orthop 2020; 7:82. [PMID: 33044584 PMCID: PMC7550549 DOI: 10.1186/s40634-020-00293-z] [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: 06/22/2020] [Accepted: 09/22/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose Angular stable implants reduced the complication rate in the treatment of humeral head fractures. But the failure rate is still high. To further reduce the risk of cut-out, cement augmentation of screws was introduced. A reason for failure of plate osteosynthesis might be the extremely high stiffness of the screw-plate interface leading to a loss of reduction and cut-out of screws. A more homogeneous distribution of the forces on all screws may avoid secondary dislocation. We hypothesize that dynamic osteosynthesis minimizes screw loosening and results in a higher load to failure than standard locking screws. Methods Twelve paired human humerus specimens were analysed. A standardized three-part fracture model with a metaphyseal defect was simulated. Within each pair of humeri, one was fixed with a Philos plate and standard locking screws (LS), whereas the other humerus was fixed with a Philos plate and dynamic locking screws (DLS). A cyclic varus-bending test or a rotation test with increasing loading force was performed until failure of the screw-bone-fixation. Results In the varus bending test, pairs failed by screw loosening in the humeral head. The LS-group reached 2901 (601–5201) load cycles until failure, while the DLS-group failed after 3731 (2001–5601) cycles. This corresponds to a median loading of 195 N for the LS-group and 235 N for the DLS-group (p = 0.028). In the rotation test the LS-group reached a median of 1101 (501–1501) load cycles until failure of fixation occurred, while the DLS-group failed after 1401 (401–2201) cycles (p = 0.225). Conclusions Plate fixation using dynamic locking screws for the treatment of proximal humerus fractures demonstrated more load cycles until failure compared to standard locking plate osteosynthesis.
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Affiliation(s)
| | - Atesch Ateschrang
- Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Germany
| | - Thomas Freude
- Department of Orthopaedics and Traumatology, University of Salzburg, Salzburg, Austria
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery, Charité - University Medical Center Berlin, Berlin, Germany
| | - Werner Schmölz
- Department of Biomechanics, University of Innsbruck, Innsbruck, Austria
| | - Christian Konrads
- Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Germany.
| | - Stefan Döbele
- Department of Trauma and Reconstructive Surgery, BG Klinik, University of Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Germany
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Varga P, Inzana JA, Fletcher JWA, Hofmann-Fliri L, Runer A, Südkamp NP, Windolf M. Cement augmentation of calcar screws may provide the greatest reduction in predicted screw cut-out risk for proximal humerus plating based on validated parametric computational modelling: Augmenting proximal humerus fracture plating. Bone Joint Res 2020; 9:534-542. [PMID: 32922762 PMCID: PMC7469511 DOI: 10.1302/2046-3758.99.bjr-2020-0053.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aims Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement. Conclusion The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation.
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Affiliation(s)
- Peter Varga
- AO Research Institute Davos, Davos, Graubünden, Switzerland
| | - Jason A Inzana
- AO Research Institute Davos, Davos, Graubünden, Switzerland.,Telos Partners, LLC, Denver, Colorado, USA
| | - James W A Fletcher
- AO Research Institute Davos, Davos, Graubünden, Switzerland.,Department for Health, University of Bath, Bath, UK
| | | | - Armin Runer
- Medical University Innsbruck, Innsbruck, Tirol, Austria
| | - Norbert P Südkamp
- Department of Orthopaedics and Trauma Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Markus Windolf
- AO Research Institute Davos, Davos, Graubünden, Switzerland
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Dauwe J, Mys K, Putzeys G, Schader JF, Richards RG, Gueorguiev B, Varga P, Nijs S. Advanced CT visualization improves the accuracy of orthopaedic trauma surgeons and residents in classifying proximal humeral fractures: a feasibility study. Eur J Trauma Emerg Surg 2020; 48:4523-4529. [PMID: 32761437 DOI: 10.1007/s00068-020-01457-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/29/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Osteosynthesis of proximal humeral fractures remains challenging with high reported failure rates. Understanding the fracture type is mandatory in surgical treatment to achieve an optimal anatomical reduction. Therefore, a better classification ability resulting in improved understanding of the fracture pattern is important for preoperative planning. The purpose was to investigate the feasibility and added value of advanced visualization of segmented 3D computed tomography (CT) images in fracture classification. METHODS Seventeen patients treated with either plate-screw-osteosynthesis or shoulder hemi-prosthesis between 2015 and 2019 were included. All preoperative CT scans were segmented to indicate every fracture fragment in a different color. Classification ability was tested in 21 orthopaedic residents and 12 shoulder surgeons. Both groups were asked to classify fractures using three different modalities (standard CT scan, 3D reconstruction model, and 3D segmented model) into three different classification systems (Neer, AO/OTA and LEGO). RESULTS All participants were able to classify the fractures more accurately into all three classification systems after evaluating the segmented three-dimensional (3D) models compared to both 2D slice-wise evaluation and 3D reconstruction model. This finding was significant (p < 0.005) with an average success rate of 94%. The participants experienced significantly more difficulties classifying fractures according to the LEGO system than the other two classifications. CONCLUSION Segmentation of CT scans added value to the proximal humeral fracture classification, since orthopaedic surgeons were able to classify fractures significantly better into the AO/OTA, Neer, and LEGO classification systems compared to both standard 2D slice-wise evaluation and 3D reconstruction model.
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Affiliation(s)
- Jan Dauwe
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland. .,Department of Orthopaedic Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Karen Mys
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Guy Putzeys
- Department of Orthopaedic and Trauma Surgery, AZ Groeninge, Kortrijk, Belgium
| | - Jana F Schader
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - R Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Peter Varga
- AO Research Institute Davos, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
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High rate of maintaining self-dependence and low complication rate with a new treatment algorithm for proximal humeral fractures in the elderly population. J Shoulder Elbow Surg 2020; 29:1127-1135. [PMID: 32057657 DOI: 10.1016/j.jse.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/28/2019] [Accepted: 11/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND We modified our treatment algorithm for proximal humeral fractures in elderly patients in 2013 to a more conservative approach avoiding locking plates. This study assesses the impact of this change on patient self-dependence. METHODS We carried out an observational comparative study including both retrospectively and prospectively collected data. For the former, 147 isolated proximal humeral fracture patients older than 65 years were treated between 2011 and 2013 at our hospital and included in a historical group. The revised treatment algorithm was applied in a similar non-concurrent, comparative patient group (n = 160) prospectively enrolled between 2015 and 2017. The primary outcome was any loss of self-dependence, with secondary outcomes including documentation of shoulder functional scores, quality of life, and adverse events. RESULTS Historical and prospective patients had similar baseline characteristics. Nonoperative treatment was performed in 53 historical patients (36%) and 83 prospective patients (78%). Prospective patients were 1.6 times less likely to lose some level of self-dependence (risk ratio, 0.62; 95% confidence interval, 0.25-1.5; P = .292), and the local adverse event risk dropped from 12.2% to 5.7% (P = .078). Mean shoulder function and quality of life were similar between the 2 groups. CONCLUSION By applying our revised algorithm, a higher proportion of elderly patients maintained their premorbid level of self-dependence and returned to their previous social environment.
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Dauwe J, Walters G, Holzer LA, Vanhaecht K, Nijs S. Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost. INTERNATIONAL ORTHOPAEDICS 2020; 44:1217-1221. [PMID: 32342142 PMCID: PMC7260263 DOI: 10.1007/s00264-020-04577-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
Purpose The issue of rising healthcare costs and limited resources is a topic of worldwide discussion over the last several decades. We hypothesized that failure of proximal humeral fracture osteosynthesis is presumed to be an important determinant in healthcare resources and related costs. The aim of this study was to calculate the total hospital-related healthcare cost of proximal humeral fracture osteosynthesis over one year focusing on failure. Methods A total of 121 patients with a proximal humeral fracture treated by angular stable osteosynthesis were included in this retrospective study. All hospital-related healthcare costs were investigated. Five main hospital-related cost categories were defined: hospitalization cost, honoraria, day care admission, materials, and pharmaceuticals. Results A total healthcare cost of € 1,139,448 was calculated for the whole patient group. Twelve patients needed revision surgery due to complications or fixation-related failure. This failure rate alone costed € 190,809 of the healthcare resources. In other words, failure after proximal humeral fracture osteosynthesis costed 17% of the total healthcare expenditure inone year. Conclusion This study demonstrates that a high amount of hospital-related healthcare resources is spent because of failure after proximal humeral fracture osteosynthesis. Further research is necessary and should investigate on how to prevent failure. This is not only in the patient’s interest, but it is also of great importance for maintaining a healthy healthcare system.
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Affiliation(s)
- Jan Dauwe
- AO Research Institute, Davos, Switzerland
- Department of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Gregory Walters
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lukas A Holzer
- Department of Orthopaedic Surgery, AUVA Trauma Center Klagenfurt, Waidmannsdorferstraße 35, 9020, Klagenfurt am Wörthersee, Austria.
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria.
| | - Kris Vanhaecht
- Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
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Knierzinger D, Crepaz-Eger U, Hengg C, Kralinger F. Does cement augmentation of the screws in angular stable plating for proximal humerus fractures influence the radiological outcome: a retrospective assessment. Arch Orthop Trauma Surg 2020; 140:1413-1421. [PMID: 32130479 PMCID: PMC7505823 DOI: 10.1007/s00402-020-03362-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Screw-tip augmentation in angular stable plating offers new possibilities for the treatment of complex proximal humerus fractures. This retrospective analysis was performed to evaluate the radiological outcome of proximal humerus fractures treated with angular stable plates and additional screw-tip cement augmentation in patients over the age of 60. MATERIALS AND METHODS A retrospective single centre analysis was conducted from June 2013 to December 2016. The minimum follow-up time was set to 6 months after surgery. Anatomical reduction and fixation were evaluated in respect to reattached tuberosities to the head fragment and the adequate restoration of the calcar area not showing any valgus or varus malalignment. Complete fracture healing was determined 3 months after surgery. Any failures such as secondary displacement, primary screw perforation, intraarticular cement leakage and avascular necrosis of the humeral head with concomitant screw cut-out were assessed. RESULTS In total, 24 patients (21 females; 3 males) at a median age of 77.5 (62-96) years were included. Five 2-part, twelve 3-part and seven 4-part fractures were detected. The measured median BMD value of 23 patients was 78.4 mg/cm3 (38.8-136.9 mg/cm3). Anatomical reduction was achieved in 50% of the patients. In most cases, the A level screws and the B1 screw were augmented with bone cement by a median of 7 (5-9) head screws used. Postoperative varus displacement was not detected in any of the patients. One patient (4.2%) sustained an early secondary displacement. Intraarticular cement leakage was detected in 3 patients (2 head-split fractures). Avascular necrosis of the humeral head was observed in 4 patients (16.7%). Revision surgery was necessary in four cases, using hemiarthroplasty twice and reverse shoulder arthroplasty the other two times. CONCLUSION Screw-tip augmentation in angular stable plating for proximal humerus fracture treatment showed a low secondary displacement rate of 4.2% in patients suffering from poor bone quality. Nevertheless, the occurrence of avascular necrosis of the humeral head with mainly severe fracture patterns observed in this study was higher compared to previously reported results in the literature. Cement augmentation in head-split fractures is not recommended, considering the high risk of an intraarticular cement leakage.
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Affiliation(s)
- Dominik Knierzinger
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Ulrich Crepaz-Eger
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Clemens Hengg
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Franz Kralinger
- Department of Trauma Surgery, Wilhelminenspital Wien, Montleartstraße 37, 1160, Vienna, Austria
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Panagiotopoulou VC, Varga P, Richards RG, Gueorguiev B, Giannoudis PV. Late screw-related complications in locking plating of proximal humerus fractures: A systematic review. Injury 2019; 50:2176-2195. [PMID: 31727401 DOI: 10.1016/j.injury.2019.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 02/07/2023]
Abstract
Locking plating is a common surgical treatment of proximal humeral fractures with satisfactory clinical results. Implant-related complications, especially screw-related, have been reported, however, the lack of information regarding their onset, used surgical technique, complexity of the fracture, bone quality etc., prevents from understanding the causes for them. The aim of this systematic review is to identify the potential risk factors for late screw complications by gathering information about the patient characteristics, comorbidities, fracture types, surgical approaches and implant types. A PubMed search was performed using humerus, fractures, bone and locking as keywords in clinical papers written in English. All abstracts and manuscripts on distal or humerus shaft fractures, and those on proximal humerus fractures without any or with only iatrogenic complications were excluded. One hundred studies met the inclusion criteria, resulting in 33% of the reported cases having at least one complication, with 11% of all complications being screw-related. Most of the latter were secondary screw perforations and screw cut-outs, being predominantly linked to poor bone quality, while screw loosening and retraction were found less frequently as a result of locking mechanism failure. Overall, the amount of information for complications was limited and screw perforation was the most frequent screw-related complication, mostly reported in female patients older than 50 years, following four-part or AO/OTA type C fractures and detected four weeks postoperatively. The sparse information in the literature could be an indicator that the late screw complications might have been under-reported and under-described, making the understanding of the screw-related complications even more challenging.
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Affiliation(s)
- Vasiliki C Panagiotopoulou
- AO Research Institute Davos, Davos, Switzerland; School of Chemical and Processing Engineering, Engineering Building, University of Leeds, UK.
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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Fletcher JWA, Windolf M, Richards RG, Gueorguiev B, Varga P. Screw configuration in proximal humerus plating has a significant impact on fixation failure risk predicted by finite element models. J Shoulder Elbow Surg 2019; 28:1816-1823. [PMID: 31036421 DOI: 10.1016/j.jse.2019.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- James W A Fletcher
- AO Research Institute Davos, Davos, Switzerland; Department for Health, University of Bath, Bath, UK
| | | | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland.
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Klug A, Wincheringer D, Harth J, Schmidt-Horlohé K, Hoffmann R, Gramlich Y. Complications after surgical treatment of proximal humerus fractures in the elderly-an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating. J Shoulder Elbow Surg 2019; 28:1674-1684. [PMID: 31056394 DOI: 10.1016/j.jse.2019.02.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/10/2019] [Accepted: 02/16/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques. METHODS Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted. RESULTS Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions <8 mm, head-shaft displacements >4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer's classification system was not predictive in either group. CONCLUSIONS RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.
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Affiliation(s)
- Alexander Klug
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany.
| | - Dennis Wincheringer
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Jasmin Harth
- Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Orthopaedicum Wiesbaden-Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Zentrum für Ellenbogenchirurgie, Wiesbaden, Germany
| | - Reinhard Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Yves Gramlich
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany
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Xie Y, Zhang L, Xiong Q, Gao Y, Ge W, Tang P. Bench-to-bedside strategies for osteoporotic fracture: From osteoimmunology to mechanosensation. Bone Res 2019; 7:25. [PMID: 31646015 PMCID: PMC6804735 DOI: 10.1038/s41413-019-0066-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 12/16/2022] Open
Abstract
Osteoporosis is characterized by a decrease in bone mass and strength, rendering people prone to osteoporotic fractures caused by low-energy forces. The primary treatment strategy for osteoporotic fractures is surgery; however, the compromised and comminuted bones in osteoporotic fracture sites are not conducive to optimum reduction and rigid fixation. In addition, these patients always exhibit accompanying aging-related disorders, including high inflammatory status, decreased mechanical loading and abnormal skeletal metabolism, which are disadvantages for fracture healing around sites that have undergone orthopedic procedures. Since the incidence of osteoporosis is expected to increase worldwide, orthopedic surgeons should pay more attention to comprehensive strategies for improving the poor prognosis of osteoporotic fractures. Herein, we highlight the molecular basis of osteoimmunology and bone mechanosensation in different healing phases of elderly osteoporotic fractures, guiding perioperative management to alleviate the unfavorable effects of insufficient mechanical loading, high inflammatory levels and pathogen infection. The well-informed pharmacologic and surgical intervention, including treatment with anti-inflammatory drugs and sufficient application of antibiotics, as well as bench-to-bedside strategies for bone augmentation and hardware selection, should be made according to a comprehensive understanding of bone biomechanical properties in addition to the remodeling status of osteoporotic bones, which is necessary for creating proper biological and mechanical environments for bone union and remodeling. Multidisciplinary collaboration will facilitate the improvement of overall osteoporotic care and reduction of secondary fracture incidence.
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Affiliation(s)
- Yong Xie
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Licheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Qi Xiong
- Department of Oncology, Chinese PLA General Hospital, Beijing, China
| | - Yanpan Gao
- State Key Laboratory of Medical Molecular Biology and Department of Immunology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Ge
- State Key Laboratory of Medical Molecular Biology and Department of Immunology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
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Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies. Arch Orthop Trauma Surg 2019; 139:1075-1099. [PMID: 30903343 DOI: 10.1007/s00402-019-03162-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Secondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies. MATERIALS AND METHODS The databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively. RESULTS Out of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II-IV and study quality was 26-70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients' clinical outcome. None of the studies showed relevant augmentation-associated complication rates. CONCLUSIONS Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs' stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.
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DeKeyser GJ, Kellam PJ, Haller JM. Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures. Orthop Clin North Am 2019; 50:159-169. [PMID: 30850075 DOI: 10.1016/j.ocl.2018.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
"The incidence of osteoporotic fracture is increasing with the aging US population. Because osteoporosis leads to a decrease in bone mineral density with a decrease in both trabecular and cortical bones, osteoporotic fracture presents fixation challenges with standard plate and screw constructs. Locked plating has been developed to create a fixed-angle plate-screw construct that is more resistant to failure in osteoporotic bone. Endosteal replacement, additional plates, and cement augmentation have all been demonstrated to further supplement osteoporotic fracture fixation. Technologies on the horizon to treat osteoporotic fracture include SMV screws, hydroxyapatite-coated implants, and far cortical locking screws."
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Affiliation(s)
- Graham J DeKeyser
- University of Utah, Department of Orthopaedics, Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Patrick J Kellam
- University of Utah, Department of Orthopaedics, Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Justin M Haller
- University of Utah, Department of Orthopaedics, Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA.
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Cement augmentation of the proximal humerus internal locking system in elderly patients: a multicenter randomized controlled trial. Arch Orthop Trauma Surg 2019; 139:927-942. [PMID: 30805708 PMCID: PMC6570671 DOI: 10.1007/s00402-019-03142-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cement augmentation of the proximal humerus internal locking system (PHILOS) screws might reduce complication rates in osteoporotic bones. This study compared the risk of mechanical failure during the first year after PHILOS™ treatment of proximal humerus fractures (PHF) without (control group) and with (augmented group) screw augmentation. Secondary objectives were to report shoulder functions, quality of life (QoL), adverse events (AEs), and reoperation rates. MATERIALS AND METHODS This multicenter randomized trial enrolled patients aged ≥ 65 years with displaced/unstable PHF from eight European centers. Randomization was performed during surgery through sealed opaque envelopes. Mechanical failures were assessed by two independent reviewers via radiographs, shoulder function by Quick DASH, SPADI, and Constant Murley scores, and QoL by EQ-5D. Follow-ups were planned at postoperative 6 weeks, 3, 6, and 12 months. RESULTS The preliminary analysis of 6-week radiographs of the first 59 enrolled patients suggested a mechanical failure rate lower than expected and the difference between groups was too small to be detected by the planned sample size of 144. The trial was prematurely terminated after 67 patients had been enrolled: 34 (27 eligible) in the control group and 33 (29 eligible) in the augmented group. Follow-ups were performed as planned. Nine patients had mechanical failures and the failure rates (95% CI) were: augmented group, 16.1% (5.5; 33.7); control group, 14.8% (4.2; 33.7); the relative risk (95% CI) for the augmented group was 1.09 (0.32; 3.65) compared to the control group (p = 1.000). No statistically significant differences in shoulder function, QoL, and AEs were observed between study groups at 1 year. Nine patients (15.8%) underwent a revision. CONCLUSIONS Due to premature termination, the study was underpowered. A larger study will be necessary to determine if cement augmentation lowers the risk of mechanical failure rate.
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Grobet C, Marks M, Tecklenburg L, Audigé L. Application and measurement properties of EQ-5D to measure quality of life in patients with upper extremity orthopaedic disorders: a systematic literature review. Arch Orthop Trauma Surg 2018; 138:953-961. [PMID: 29654354 DOI: 10.1007/s00402-018-2933-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The EuroQol-5 Dimension (EQ-5D) is the most widely used generic instrument to measure quality of life (QoL), yet its application in upper extremity orthopaedics as well as its measurement properties remain largely undefined. We implemented a systematic literature review to provide an overview of the application of EQ-5D in patients with upper extremity disorders and analyse its measurement properties. MATERIALS AND METHODS We searched Medline, EMBASE, Cochrane and Scopus databases for clinical studies including orthopaedic patients with surgical interventions of the upper extremity who completed the EQ-5D. For all included studies, the use of EQ-5D and quantitative QoL data were described. Validation studies of EQ-5D were assessed according to COSMIN guidelines and standard measurement properties were examined. RESULTS Twenty-three studies were included in the review, 19 of which investigated patients with an intervention carried out at the shoulder region. In 15 studies, EQ-5D assessed QoL as the primary outcome. Utility index scores in non-trauma patients generally improved postoperatively, whereas trauma patients did not regain their recalled pre-injury QoL levels. EQ-5D measurement properties were reported in three articles on proximal humerus fractures and carpal tunnel syndrome. Positive ratings were seen for construct validity (Spearman correlation coefficient ≥ 0.70 with the Short Form (SF)-12 or SF-6D health surveys) and reliability (intraclass correlation coefficient ≥ 0.77) with intermediate responsiveness (standardised response means: 0.5-0.9). However, ceiling effects were identified with 16-48% of the patients scoring the maximum QoL. The methodological quality of the three articles varied from fair to good. CONCLUSIONS For surgical interventions of the upper extremity, EQ-5D was mostly applied to assess QoL as a primary outcome in patients with shoulder disorders. Investigations of the measurement properties were rare, but indicate good reliability and validity as well as moderate responsiveness in patients with upper extremity conditions.
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Affiliation(s)
- Cécile Grobet
- Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
| | - Miriam Marks
- Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Linda Tecklenburg
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Gertrudstrasse 15, 8401, Winterthur, Switzerland
| | - Laurent Audigé
- Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
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Abstract
PURPOSE OF REVIEW This review examines recent literature regarding the clinical management of fragility fractures, provides insight into new practice patterns, and discusses controversies in current management. RECENT FINDINGS There are declining rates of osteoporosis management following initial fragility fracture. Management of osteoporotic fractures via a multidisciplinary team reduces secondary fracture incidence and improves overall osteoporotic care. Anabolic agents (abaloparatide and teriparatide) are effective adjuvants to fracture repair, and have shown positive results in cases of re-fracture in spite of medical management (i.e., bisphosphonates). For AO 31-A1 and A2 intertrochanteric hip fractures (non-reverse obliquity), no clinical advantage of intramedullary fixation over the sliding hip screw (SHS) has been proven; SHS is more cost-effective. As fragility fracture incidence continues to rise, orthopedic surgeons must play a more central role in the care of osteoporotic patients. Initiation of pharmacologic intervention is key to preventing subsequent fragility fractures, and may play a supportive role in initial fracture healing. While the media bombards patients with complications of medical therapy (atypical femur fractures, osteonecrosis of jaw, myocardial infarction), providers need to understand and communicate the low incidence of these complications compared with consequences of not initiating medical therapy.
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Affiliation(s)
- Adam Z Khan
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard D Rames
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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Varga P, Inzana JA, Gueorguiev B, Südkamp NP, Windolf M. Validated computational framework for efficient systematic evaluation of osteoporotic fracture fixation in the proximal humerus. Med Eng Phys 2018; 57:29-39. [PMID: 29728330 DOI: 10.1016/j.medengphy.2018.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 02/20/2018] [Accepted: 04/19/2018] [Indexed: 12/24/2022]
Abstract
The high rate of fixation failure in osteoporotic proximal humerus fractures indicate the need for improved solutions. Computer simulations may help to overcome the limitations of the gold standard biomechanical testing in evaluating the performance of new implants and enhance the effectivity and outcome of the design process. This study presents a framework for automated computational analysis that facilitates efficient and systematic evaluation of proximal humerus fracture plating under a variety of conditions including bone quality, fracture pattern, implant configuration and loading regime. The underlying finite element methodology was previously validated. The capabilities of the software tool are demonstrated by virtually reproducing a previously published biomechanical study on the effect of screw augmentation and showing that the models capture the essence of the experimental results. Due to the modular design of the framework, the currently available set of angle-stable plate implants can be readily expanded to include other fixations such as intramedullary nails. Besides the capability to compare already existing solutions, the tool can provide rapid feedback on novel ideas. Therefore, it is expected to efficiently complement and partially replace expensive experimental tests and aid development and optimization of implant designs for improved fixation of osteoporotic proximal humerus fractures.
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Affiliation(s)
- Peter Varga
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland.
| | - Jason A Inzana
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Norbert P Südkamp
- Orthopedics and Trauma Department, University Hospital Freiburg, Breisacher Str. 86, 79110 Freiburg im Breisgau, Germany
| | - Markus Windolf
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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Abstract
Osteoporosis is one of the costliest conditions managed by orthopaedic surgeons. This condition, which is characterized by decreased bone density and thinning of cortical bone, is strongly influenced by complex signaling in both the hormonal and mechanical environments. Osteoporosis cannot be cured; instead, it can only be managed to decrease patient morbidity. Current pharmacologic treatments are aimed at minimizing bone turnover and have substantial side effects. Therefore, much work remains to find safer and more effective agents to restore bone density. In addition to the high incidence of fracture in elderly patients, many of the traditional fixation constructs used for repair of these fractures are not suitable for use in osteoporotic bone. Increased use of fixed-angle locking plates, intramedullary devices, and bone substitutes has greatly improved outcomes in these patients.
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Varga P, Grünwald L, Windolf M. The prediction of cyclic proximal humerus fracture fixation failure by various bone density measures. J Orthop Res 2018; 36:2250-2258. [PMID: 29469187 DOI: 10.1002/jor.23879] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/15/2018] [Indexed: 02/04/2023]
Abstract
Fixation of osteoporotic proximal humerus fractures has remained challenging, but may be improved by careful pre-operative planning. The aim of this study was to investigate how well the failure of locking plate fixation of osteoporotic proximal humerus fractures can be predicted by bone density measures assessed with currently available clinical imaging (realistic case) and a higher resolution and quality modality (theoretical best-case). Various density measures were correlated to experimentally assessed number of cycles to construct failure of plated unstable low-density proximal humerus fractures (N = 18). The influence of density evaluation technique was investigated by comparing local (peri-implant) versus global evaluation regions; HR-pQCT-based versus clinical QCT-based image data; ipsilateral versus contralateral side; and bone mineral content (BMC) versus bone mineral density (BMD). All investigated density measures were significantly correlated with the experimental cycles to failure. The best performing clinically feasible parameter was the QCT-based BMC of the contralateral articular cap region, providing significantly better correlation (R2 = 0.53) compared to a previously proposed clinical density measure (R2 = 0.30). BMC had consistently, but not significantly stronger correlations with failure than BMD. The overall best results were obtained with the ipsilateral HR-pQCT-based local BMC (R2 = 0.74) that may be used for implant optimization. Strong correlations were found between the corresponding density measures of the two CT image sources, as well as between the two sides. Future studies should investigate if BMC of the contralateral articular cap region could provide improved prediction of clinical fixation failure compared to previously proposed measures. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Peter Varga
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, 7270, Switzerland
| | - Leonard Grünwald
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, 7270, Switzerland
- Department of Traumatology and Reconstructive Surgery, BG Traumacenter Tübingen, University of Tübingen, Germany
| | - Markus Windolf
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, 7270, Switzerland
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Mazzucchelli RA, Jenny K, Zdravkovic V, Erhardt JB, Jost B, Spross C. The influence of local bone quality on fracture pattern in proximal humerus fractures. Injury 2018; 49:359-363. [PMID: 29287662 DOI: 10.1016/j.injury.2017.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/13/2017] [Accepted: 12/22/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bone mineral density and fracture morphology are widely discussed and relevant factors when considering the different treatment options for proximal humerus fractures. It was the aim of this study to investigate the influence of local bone quality on fracture patterns of the Neer classification as well as on fracture impaction angle in these injuries. MATERIALS AND METHODS All acute, isolated and non-pathological proximal humerus fractures admitted to our emergency department were included. The fractures were classified according to Neer and the humeral head impaction angle was measured. Local bone quality was assessed using the Deltoid Tuberosity Index (DTI). The distribution between DTI and fracture pattern was analysed. RESULTS 191 proximal humerus fractures were included (61 men, mean age 59 years; 130 women, mean age 69.5). 77 fractures (40%) were classified as one-part, 72 (38%) were two-part, 24 (13%) were three- and four-part and 18 (9%) were fracture dislocations. 30 fractures (16%) were varus impacted, whereas 45 fractures (24%) were classified as valgus impacted. The mean DTI was 1.48. Valgus impaction significantly correlated with good bone quality (DTI ≥ 1.4; p = 0.047) whereas no such statistical significance was found for the Neer fracture types. DISCUSSION We found that valgus impaction significantly depended on good bone quality. However, neither varus impaction nor any of the Neer fracture types correlated with bone quality. We conclude that the better bone quality of valgus impacted fractures may be a reason for their historically benign amenability to ORIF. On the other hand, good local bone quality does not prevent fracture comminution.
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Affiliation(s)
- Ruben A Mazzucchelli
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Katharina Jenny
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Vilijam Zdravkovic
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Johannes B Erhardt
- Department of Orthopaedics, Spital Grabs, Spitalstrasse 44, 9472, Grabs, Switzerland.
| | - Bernhard Jost
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
| | - Christian Spross
- Department of Orthopaedics and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
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Kavuri V, Bowden B, Kumar N, Cerynik D. Complications Associated with Locking Plate of Proximal Humerus Fractures. Indian J Orthop 2018; 52:108-116. [PMID: 29576637 PMCID: PMC5858203 DOI: 10.4103/ortho.ijortho_243_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Proximal humerus fractures constitute a significant percentage of fragility fractures. The growing use of locking plate has helped treat this problem, but at the same time has brought about complications. Past systematic reviews have documented these complications, however a large number of recent studies have been published since, reporting their own complication rates with different techniques. This study reviews the current complications associated with locking plate of proximal humerus fractures as well as methods to reduce them. A systematic review, following the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using PubMed, Scopus, and Cochrane databases, to evaluate locking plate fixation (and complications) of traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of 12-month postoperative followup, articles within the last 5 years, and studies with >10 participants. Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery and Centre for Evidence-Based Medicine guidelines. The initial query identified 51,206 articles from multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal humerus fractures treated with locking plates. Intraarticular screw penetration was the most reported complication (9.5%), followed by varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), nonunion (1.5%), and deep infection (1.4%). Reoperation occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-related complications, which in turn were the main reasons for reoperation. The authors of these studies discussed different techniques that could be used to address these issues. Expanding use of locking plate in the proximal humerus fractures leads to improvements and advancements in surgical technique. Further research is necessary to outline indications to decrease complications, further.
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Affiliation(s)
- Venkat Kavuri
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA,Address for correspondence: Dr. Venkat Kavuri, Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, 245 N. 15th St. M.S. 420, Philadelphia, PA 19103, USA. E-mail:
| | - Blake Bowden
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Neil Kumar
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Doug Cerynik
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
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Fatigue failure of plated osteoporotic proximal humerus fractures is predicted by the strain around the proximal screws. J Mech Behav Biomed Mater 2017; 75:68-74. [DOI: 10.1016/j.jmbbm.2017.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/19/2017] [Accepted: 07/03/2017] [Indexed: 01/20/2023]
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The Applications of Finite Element Analysis in Proximal Humeral Fractures. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017; 2017:4879836. [PMID: 29081829 PMCID: PMC5610852 DOI: 10.1155/2017/4879836] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/06/2017] [Indexed: 12/18/2022]
Abstract
Proximal humeral fractures are common and most challenging, due to the complexity of the glenohumeral joint, especially in the geriatric population with impacted fractures, that the development of implants continues because currently the problems with their fixation are not solved. Pre-, intra-, and postoperative assessments are crucial in management of those patients. Finite element analysis, as one of the valuable tools, has been implemented as an effective and noninvasive method to analyze proximal humeral fractures, providing solid evidence for management of troublesome patients. However, no review article about the applications and effects of finite element analysis in assessing proximal humeral fractures has been reported yet. This review article summarized the applications, contribution, and clinical significance of finite element analysis in assessing proximal humeral fractures. Furthermore, the limitations of finite element analysis, the difficulties of more realistic simulation, and the validation and also the creation of validated FE models were discussed. We concluded that although some advancements in proximal humeral fractures researches have been made by using finite element analysis, utility of this powerful tool for routine clinical management and adequate simulation requires more state-of-the-art studies to provide evidence and bases.
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