Abstract
Background:Humeral head fractures and their postoperative outcome remain a challenging problem in surgical daily routine. Predictive factors for loss of fixation are rare.Objective:Determination of predictive factors for the failure of osteosynthesis with the loss of fixation or migration of screws in humeral head fractures.Method:From 1995 to 2011, 408 patients with proximal humeral fractures [mean age 66.6 years, 50.9-82.3 years] and osteosynthesis were analyzed. Two hundred and three received open reduction internal fixation (ORIF) with the PHILOS® plate. The non-locking plate was used in 80, the locking plate in 16 and humeral head prosthesis in 26 patients, in addition to 23 patients undergoing other procedures. Intraoperative reduction that achieved an anatomical alignment of the medial aspect of the humerus (humeral calcar) was assessed in 94 patients by postoperative X-ray analysis. The loss of fixation was evaluated by a follow-up of three to five X-rays and measurement of the humeral tip-apex-distance (HTAD).Results:For stable fixed fractures with an intact calcar, percentual HTAD was significantly higher than for unstable fixed fractures (p=0.04). Morbidity, such as hypertension, orthopedic operations or diabetes, strongly influenced the HTAD, while postoperative passive motion treatment modestly affected the HTAD over time.Conclusion:The anatomic reconstruction of the calcar, leading to stable fixation of humeral head fractures, can significantly prevent an overproportioned decrease in the HTAD in postoperative X-rays and seems to be vital in multimorbid patients. Measurement of the HTAD over time delivers a tool for early detection of secondary loss of fixation.
Highlights
Fractures of the proximal humerus account for approximately 6% of all adult fractures [1]
The loss of surgical fixation depends on the age, local bone morphogenic density (BMD) and anatomic reduction, especially of the medial cortical support/calcar [8 - 12]
Because the humeral tip-apex-distance (HTAD) of the first X-ray is normally defined as 100%, the distance determined during the following Xrays normally falls below 100%, but it may exceed 100% because of imaging variations
Summary
Fractures of the proximal humerus account for approximately 6% of all adult fractures [1]. Some (distinct) undisplaced fractures may be sufficiently treated with conservative therapy [2], while displaced and unstable fractures need to be treated surgically [3, 4]. There is an evidence that dislocated three- and four-party fractures may be sufficiently treated conservatively [5]. The loss of surgical fixation depends on the age, local bone morphogenic density (BMD) and anatomic reduction, especially of the medial cortical support/calcar [8 - 12]. Predictable factors of implant failure with loss of fixation are rare, and radiographic detection of cut-out [13] and osteonecrosis, especially in complex fractures [14 - 16], remains challenging. Humeral head fractures and their postoperative outcome remain a challenging problem in surgical daily routine. Predictive factors for loss of fixation are rare
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