Indirect reduction maneuver and minimally invasive approach for displaced proximal humerus fractures in elderly patients

Characteristics and functional outcomes of varus displaced proximal humerus fractures

BACKGROUND

The purpose of this study was to compare fracture characteristics and functional outcomes between patients with proximal humerus fractures with and without initial varus displacement.

METHODS

A retrospective review of 325 patients with proximal humerus fractures was performed. Patients with initial varus displacement were placed in Varus cohort and were age- and sex-matched 1:1 with a second cohort presenting proximal humerus fractures without varus displacement, referred to as Fracture cohort. Varus fracture displacement was defined when the most proximal aspect of humeral head was below the most proximal aspect of greater tuberosity on initial radiographs, and the head shaft angle was <130°.

RESULTS

There were 60 patients in V cohort and 60 patients in F cohort. Statistical analysis revealed that there were significant differences in initial horizontal offset (38.8 vs. 45.9 mm), initial anterior angulation angle (36.5° vs. 16.4°), postoperative head shaft angle (132.2° vs. 141.3°), last head shaft angle (122.2° vs. 138.5°), difference for head shaft angles (10.0° vs. 2.7°), postoperative horizontal offset (43.4 vs. 45.3 mm), last horizontal offset (38.4 vs. 42.8 mm), difference for offsets (4.9 vs. 2.5 mm), complications (15 vs. 7 cases), and revision surgery (7 vs. 1 case) between two cohorts. Overall satisfactory results were achieved in most patients regardless of varus displacement, pain-VAS and Constant scores in V cohort were inferior to the scores in F cohort. The cut-off value of postoperative head shaft angle for good/excellent outcomes was 135.5° using receiver operating characteristic curve analyses.

CONCLUSION

Varus displaced proximal humerus fractures were accompanied by decreased horizontal offset and increased anterior angulation angle, and had a course of more varization and horizontal shortening compared with those without initial varus displacement. Patients with varus displaced fractures were associated with worse functional outcomes, and these factors might affect functional outcomes.

LEVEL OF EVIDENCE

Prognostic, cohort study, Level III.

ANTEROLATERAL APPROACHES FOR PROXIMAL HUMERAL OSTEOSYNTHESIS: A SYSTEMATIC REVIEW

Objective:

Anterolateral approaches for proximal humerus osteosynthesis have great advantages because they allow direct exposure of the lateral aspect of the humerus without the muscular retraction seen in the deltopectoral approach. However, much resistance is found among surgeons due to the potential risk of iatrogenic injury to the axillary nerve. To identify the incidence of axillary nerve iatrogenic lesions and evaluate the functional results of proximal humerus osteosynthesis with locking plates using anterolateral approaches.

Methods:

The literature review followed the PRISMA protocol.

Results:

A total of 23 articles were selected from 786 patients submitted to anterolateral approaches. Three cases (0.38%) of iatrogenic axillary nerve lesions were confirmed. The results of the functional tests were similar to those of the deltopectoral approach.

Conclusion:

Anterolateral approaches are a viable and safe alternative for proximal humerus osteosynthesis with locking plate. Subacromial impingement was the most frequent complication. Level of Evidence II, Systematic Review.

[Application of the modified internal fixation method of minimally invasive percutaneous plate osteosynthesis in treatment of proximal humeral fracture]

OBJECTIVE

To study the clinical outcomes and characteristics of fracture healing of a modified internal fixation method, which was implemented by placing four and two screws respectively at the proximal and distal end of the locking plate in the minimally invasive percutaneous plate osteosynthesis (MIPPO) for patients with proximal humeral fractures.

METHODS

Patients in Peking University Third Hospital from February 2010 to December 2016 were brought into this retrospective study. Based on different operation methods, they were divided into minimally invasive (MI) group and non-minimally invasive (non-MI) group, and the patients in MI group were performed with the modified internal fixation. In order to observe the varying efficacy for different fracture types between the two groups, we further investigated the patients with Neer two-part and three-part fracture, respectively. The follow-up parameters included general physical examination, X-ray, visual analogue scale (VAS) and Constant-Murley score.

RESULTS

A total of 117 patients with an average age of (61.5±16.2) years met the inclusion criteria, and MI group included 45 patients, non-MI group included 72 patients. According to the Neer classification, there were 46 cases of two-part fracture, 63 cases of three-part fracture and 8 cases of four-part fracture. In MI group, there were 17 males and 28 males with an average age of (62.2±17.1) years, including 18 cases of two-part fracture, 23 cases of three-part fracture and 4 cases of four-part fracture. In non-MI group, there were 27 males and 45 females with an average age of (60.1±17.7) years, including 28 cases of two-part fracture, 40 cases of three-part fracture and 4 cases of four-part fracture. There were no significant differences between the two groups in terms of gender (P=0.975), age (P=0.545) and fracture type (P=0.756). The average hospital-stay in MI group and non-MI group was (2.8±1.1) days and (4.3±1.3) days (P=0.023), the operation time was (67.8±14.9) min and (102.3±34.1) min (P<0.001), the blood loss was (21.3±6.5) mL and (181.5±55.6) mL (P<0.001), the Constant-Murley score was 6.1±0.9 and 6.5±0.8 (P=0.032) one week after surgery, and the Constant-Murley score was 66.1±4.3 and 63.4±4.9 (P=0.006) three months after surgery, MI group had significant advantages in these aspects. In terms of Neer two-part and three-part fracture, the VAS score (5.9±0.8) one week postoperatively and the Constant-Murley score (66.6±3.7) three months postoperatively were significantly superior in MI group (P<0.05). In MI group, delayed fracture healing occurred in 1 case (2.2%) and abduction was restricted in 1 case (2.2%). In non-MI group, delayed fracture healing occurred in 3 cases (4.2%) and abduction was restricted in 2 cases (2.8%). There were no internal fixation complications and humeral head necrosis in both groups.

CONCLUSION

Applying the modified internal fixation in MIPPO to cure proximal humeral fractures is effective clinically with thick callus formation occurring at the fracture site. The fracture can achieve normal healing and the shoulder functions can restore well, indicating the modified surgical method is a good treatment option.

Minimally Invasive Plate Osteosynthesis for Proximal Humerus Fractures: A Retrospective Study Describing Principles and Advantages of the Technique

BACKGROUND

The aim of this study was to evaluate the clinical and radiographic results after minimally invasive plate osteosynthesis (MIPO) for proximal humerus fractures. Potential advantages of this approach include the easier exposure of the greater tuberosity and the limited surgical dissection around the fracture site.

MATERIALS AND METHODS

From October 2011 to March 2016, thirty-nine patients (32 women, 7 men) with a mean age of 64.9 years (range: 48-80) were surgically treated with the MIPO technique for proximal humeral fractures. According to Neer classification, there were 12 two-part, 24 three-part, and 2 four-part fractures and 1 two-part fracture-dislocation; the AO/OTA system was also used to categorize the fractures. The Constant-Murley (CMS) and the Oxford Shoulder (OSS) Scores were used to evaluate shoulder function.

RESULTS

Thirty-four patients were available for clinical and radiographic evaluation at a mean follow-up of 31.8 months (range: 12-54 months). All fractures healed and no postoperative complications occurred. Full recovery of pretrauma activities was reported by 27 patients, while 7 patients presented mild functional limitations. The mean absolute CMS was 75.2 (range: 55-95), the mean normalized CMS was 90.5 (range: 69-107), and the mean OSS was 43.7 (range: 31-48). The only statistically significant correlation was found between the female gender and lower absolute CMS and OSS. Radiographic evaluation revealed varus malunion in 4 cases and valgus malunion in 1 case, while incomplete greater tuberosity reduction was detected in 4 cases. All malunions were related to inadequate reduction at time of surgery and not to secondary displacement.

CONCLUSIONS

MIPO for proximal humeral fractures is an effective and safe surgical procedure. The limited tissue dissection allows minimizing the incidence of nonunion, avascular necrosis, and infection. The technique is not easy, requires experience to achieve mastery, and should be reserved for selected fracture patterns. In our experience, the main advantage of this approach consists in the direct access to the greater tuberosity, thus facilitating its anatomic reduction and fixation.

Cut-off values of the Japanese Orthopaedic Association score corresponding to Constant scores for evaluating outcomes in rotator cuff tear

PURPOSE

To clarify the cut-off value of the Japanese Orthopaedic Association (JOA) score corresponding to rotator cuff tear outcome as evaluated by the Constant score.

METHODS

The subjects were 230 patients with rotator cuff tear. The Constant and JOA scores on the first examination in our hospital were evaluated. After investigation of the correlation between the Constant and JOA scores, the cut-off JOA score was calculated, corresponding to excellent, good and fair outcomes as evaluated by the Constant score.

RESULTS

The Constant and JOA scores on the first examination were 49.64 ± 12.84 and 72.52 ± 12.84, respectively, with a strong correlation ( r = 0.87, p < 0.01). Receiver operating characteristic analysis revealed that the cut-off JOA score was 87.0 for excellent outcome (area under the curve, AUC: 0.93; sensitivity: 100%; specificity: 88.6%; p < 0.01), 84.0 for good outcome (AUC: 0.94; sensitivity: 100%; specificity: 83.4%; p < 0.01) and 78.0 for fair outcome (AUC: 0.88; sensitivity: 100%; specificity: 71.3%; p < 0.01).

CONCLUSIONS

In patients with rotator cuff tear, good outcome as judged by a Constant score of ≥80 corresponds to a JOA score cut-off of 84.0. Judgement of the treatment outcomes and evaluation of the surgical method may be more accurate when using clear cut-off values for the scoring system employed, such as those determined in our study.

Influence of age, gender, and radiographic features on the deltoid splitting approach for surgical osteosynthesis in displaced proximal humerus fractures: a comparison study

BACKGROUND

The deltoid splitting approach has recently been widely adopted to facilitate less invasive procedures for proximal humerus fractures. However, there are still concerns regarding its effectiveness in aging people and in cases involving complex fractures. This study was conducted to evaluate the efficacy of a proximal humeral locking plate using the anterolateral deltoid splitting approach and to specifically examine the effect of patient age, gender, and fracture pattern on surgical outcomes.

METHODS

Forty-two cases of proximal humeral fractures treated using the deltoid splitting approach and locking plate fixation were reviewed. Outcome differences were evaluated in terms of age, gender distribution, and radiographic analysis based on the Neer Classification. The influence of the surgical approach was further investigated by age-matched paired analysis after subdividing patients into two age groups (younger than 60 years vs. older than 60 years; N = 21, in each group).

RESULTS

In total, 41 patients (98%) demonstrated fracture union. The average Constant score was 80.4. No significant differences were found between patients younger than 60 years, and the older patients. Higher mean scores were found in men than in women (p = 0.448) and in simple fractures than in complex fractures (p = 0.454), without any significant differences. Better postoperative functional outcomes were observed when the humeral head-neck angle was greater than 105°, with a significant difference (p = 0.000). Surgical complications were found in 16 patients (38%) without significant difference between two age groups (p = 0.268). The most common complication was screw penetration.

CONCLUSIONS

Anterolateral deltoid splitting using locking plate fixation provided a feasible alternative for surgery of proximal humerus fractures in different age groups and yielded comparable outcomes when the neck-shaft angle was properly restored. Surgeons must be cautious regarding potential complications, especially with screw penetration when using the locking plate through a less invasive approach.

TRIAL REGISTRATION

ISRCTN75494532 . Trial Date: 2017/01/31.

Minimally Invasive Plate Osteosynthesis Using a Screw Compression Method for Treatment of Humeral Shaft Fractures

Background

This study aims to compare the surgical outcomes of open reduction and internal fixation (ORIF) and minimally invasive plate osteosynthesis (MIPO) using a screw compression method in simple humeral shaft fractures.

Methods

This retrospective study was performed with 50 patients who had surgical interventions for the treatment of simple humeral shaft fractures and had follow-ups of at least 12 months in Ulsan University Hospital between August 2008 and June 2015. Group 1 included 23 patients treated with ORIF and group 2 included 27 patients treated with the MIPO technique using a locking screw plate. The time to clinical/radiographic union, the joint range of motion (ROM), and function were evaluated.

Results

The average time to clinical/radiographic bone union was shorter in group 2 (12.0 ± 3.7 weeks/14.8 ± 2.0 weeks in group 1 and 9.4 ± 1.3 weeks/12.0 ± 3.3 weeks in group 2; p = 0.022/p = 0.034). Shoulder and elbow joint function evaluated by joint ROM and visual analogue scale (VAS), Korean Shoulder Elbow Society (KSS), American Shoulder and Elbow Surgeons (ASES), and the University of California at Los Angeles (UCLA) scores was excellent in both groups. On the average shoulder ROM at 12 months after the operation, group 1 had forward elevation of 160°, external rotation of 30° in adduction and lumbar vertebra 10 level in internal rotation and group 2 had forward elevation of 170°, external rotation of 35° in adduction and lumbar vertebra 9 level in internal rotation. The mean VAS, KSS, ASES, and UCLA scores were 2.8, 87.0 ± 0.9, 89.4 ± 0.9, and 31.0 ± 1.4, respectively, in group 1 and 1.7, 89.1 ± 2.7, 91.0 ± 1.6, and 32.4 ± 3.2, respectively, in group 2. There were statistically significant intergroup differences in VAS score (p = 0.011). There were significantly less postoperative infections in group 2 (three cases, 10.7% in group 1 and 0 case in group 2; p = 0.041) although all of them were superficial infections and well-treated by an average 4-week course of antibiotics (range, 2 to 6 weeks).

Conclusions

MIPO using a screw compression method in simple humeral shaft fractures demonstrated superior efficacy to ORIF in terms of the time to clinical/radiographic union, pain score, and postoperative infection rate.

Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures

OBJECTIVES

The aim of the present study was to evaluate results, including clinical and radiological outcomes and number of complications, following minimally invasive plate osteosynthesis (MIPO) of proximal humerus fractures, using the PHILOS® proximal humerus internal locking system (Synthes Holding AG, Solothurn, Switzerland).

METHODS

Retrospectively evaluated were 31 patients treated with MIPO (12 male, 19 female; average age: 58.4 years). Four patients had 2-part fractures, 14 patients had 3-part fractures, and 13 patients had 4-part fractures, according to Neer classification. Healing, complications, and head-shaft angle (HSA) were radiographically evaluated. Clinical outcomes were assessed at 1-year follow-up with Constant score.

RESULTS

Average Constant scores for fractured and normal shoulders were 73.2 ± 10.9 and 84.8 ± 5.1, respectively. Varus progression, fracture type, and age had no significant effect on functional outcome. Average postoperative and follow-up HSA's were 130.80 ± 7.70 and 128.80 ± 10.00, respectively. Significant varus progression was observed during follow-up (p = 0.01). Varus progression was more prominent in patients with postoperative HSA < 130° (p < 0.001). Inferomedial calcar screw usage, fracture type, and age had no significant effect on varus progression. Complications included 2 implant failures, 1 case of avascular necrosis (AVN), 1 primary screw cut-out, 1 axillary nerve injury, and 1 radial nerve injury (22.6% overall).

CONCLUSION

MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. Reduction may be difficult, resulting in varus progression. Another disadvantage is risk of axillary nerve injury. Careful surgical technique and correct implant selection is important in the prevention of nerve injury.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery

OBJECTIVES

This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures.

DESIGN

Retrospective study.

SETTING

University trauma center.

PATIENTS AND INTERVENTION

We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011.

MAIN OUTCOME MEASUREMENTS

Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure.

RESULTS

Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss.

CONCLUSIONS

Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Lessons learned from treating patients with unstable multifragmentary fractures of the proximal humerus by minimal invasive plate osteosynthesis

INTRODUCTION

The authors present clinical and radiographic results of minimal invasive plate osteosynthesis (MIPO) for three- or four-part fractures of the proximal humerus.

PATIENTS AND METHODS

Twenty-six patients with three- or four-part proximal humeral fractures treated with the MIPO technique through the deltoid splitting approach were clinically and radiographically evaluated at a minimum of 12 months with an average of 20.1 months. The valgus-impacted type of three-part fracture was excluded to verify the results of the MIPO with unstable multifragmentary fractures of the proximal humerus.

RESULTS

Twenty female patients and six male patients were included (mean age 67 years; range 18-90 years). No cases of nonunion were seen. The mean forward flexion, abduction, and external rotation were 145°, 119°, and 48°, respectively. The mean visual analog scale (VAS) for pain was 1.47 points. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 14.5 points, and the mean UCLA score was 29.6 points. The mean neck-shaft angle was 134°. Twenty-three patients had adequate medial support, and three patients did not have adequate medial support on initial postoperative radiographs. Five shoulders (19 %) developed complicated results. Two cases of proximal malposition of the plate (7.7 %) and two intra-articular screw penetrations (7.7 %) were observed. One case of osteonecrosis of the humeral head was identified at the final follow-up (3.8 %).

CONCLUSION

The MIPO technique provides reliable radiologic and functional outcomes for three- and four-part proximal humeral fractures. Our results might support the use of MIPO for treating unstable multi fragmentary fractures of proximal humerus such as three- or four-part fractures to decrease osteonecrosis of humeral head.