Fixation Of Proximal Humeral Fractures Research Articles

Single-screw Fixation of Adolescent Salter-II Proximal Humeral Fractures: Biomechanical Analysis of the "One Pass Door Lock" Technique.

Pin fixation of Salter-II proximal humeral fractures in adolescents approaching skeletal maturity has potential complications that can be avoided with single-screw fixation. However, the strength of screw fixation relative to parallel and diverging pin fixation is unknown. To compare the biomechanical fixation strength between these fixation modalities, we used synthetic composite humeri, and then compared these results in composite bone with cadaveric humeri specimens. Parallel pinning, divergent pinning, and single-screw fixation repairs were performed on synthetic composite humeri with simulated fractures. Six specimens of each type were tested in axial loading and other 6 were tested in torsion. Five pair of cadaveric humeri were tested with diverging pins and single screws for comparison. Single-screw fixation was statistically stronger than pin fixation in axial and torsional loading in both composite and actual bone. There was no statistical difference between composite and cadaveric bone specimens. Single-screw fixation can offer greater stability to adolescent Salter-II fractures than traditional pinning. Single-screw fixation should be considered as a viable alternative to percutaneous pin fixation in transitional patients with little expected remaining growth.

Ultrasound evaluation of the rotator cuff after osteosynthesis of proximal humeral fractures with locking intramedullary nail

ObjectiveTo evaluate supraspinatus tendon integrity with ultrasound (US) in patients submitted to proximal humeral fracture (PHF) fixation with a locking intramedullary nail. MethodsThirty-one patients with PHF treated with curvilinear locking intramedullary nail, aged between 50 and 85 years, were assessed by US at six months postoperatively and clinically at six and 12 months postoperatively. The primary aim was supraspinatus tendon integrity, evaluated by US at six months postoperatively. Secondary aims included the Constant-Murley, DASH score, and visual analog pain scores, as well as complications and reoperation rates. ResultsFull-thickness rotator cuff ruptures were observed in four patients (13%), supraspinatus ruptures in three cases (10%), and subscapularis ruptures in one case (3%). Partial ruptures were diagnosed in 10 cases (32%). The results using the Constant-Murley score at 12 months were 71.3±15.2 points for the entire series, with 73.2±16.1 points for patients without rotator cuff ruptures and 68.7±14.1 points for those with partial or complete ruptures, without a statistically significant difference (p=0.336). Complications, exclusively for rotator cuff ruptures, were observed in nine patients (29%). ConclusionA high rate of rotator cuff ruptures was demonstrated, with partial ruptures in 32% of cases and full-thickness ruptures in 13%. However, clinical results are satisfactory, and are not influenced by the presence of rotator cuff ruptures.

The female geriatric proximal humeral fracture: protagonist for straight antegrade nailing?

IntroductionStraight antegrade humeral nailing (SAHN) has become a standard technique for the surgical fixation of proximal humeral fractures, which predominantly affect elderly females. The nail’s proximal anchoring point has been demonstrated to be critical to ensure reliable fixation in osteoporotic bone and to prevent iatrogenic damage to the superior rotator cuff bony insertion. Anatomical variations of the proximal humerus, however, may preclude satisfactory anchoring of the nail’s proximal end and may bare the risk of rotator cuff violation, even though the nail is inserted as recommended. The aim of this study was to evaluate the anatomical suitability of proximal humeri of geriatric females aged 75 years and older for SAHN. Specifically, we sought to assess the proportion of humeri not anatomically amenable to SAHN for proximal humeral fracture.Materials and MethodsA total of 303 proximal humeri of 241 females aged 75 years and older (mean age 84.5 ± 5.0 years; range 75–102 years) were analyzed for this study. Multiplanar two-dimensional reformations (true ap, true lateral, and axial) were reconstructed from shoulder computed tomography (CT) data sets. The straight antegrade nail’s ideal entry point, “critical point” (CP), and critical distance (CD; distance between ideal entry point and CP) were determined. The rate of proximal humeri not anatomically suitable for SAHN (critical type) was assessed regarding proximal reaming diameters of currently available straight antegrade humeral nails.ResultsOverall, 35.6% (108/303) of all proximal humeri were found to be “critical types” (CD <8 mm) as to the recommended minimal proximal reaming diameter of 10 mm of straight antegrade nails currently in use. Moreover, 43.2% (131/303) of the humeri were considered “critical types” with regard to the alternatively used larger proximal reaming diameter of 11.5 mm. Mean CD was 9.0 ± 1.7 mm (range 3.5–13.5 mm) and did not correlate with age (r = −0.04, P = 0.54). No significant differences in CD and rate of “critical types” were found between left and right humeri as well as between females aged between 75 and 84 years (n = 151) and females aged 85 and older (n = 152).ConclusionsMore than a third of proximal humeri of geriatric females are “critical types” as to SAHN and may, therefore, be at risk for procedure-related complications, such as rotator cuff violation, fixation failure, and potential malreduction. In view of this finding, we recommend to routinely analyze multiplanar CT reformations of the uninjured contralateral side prior to surgery to improve selection of patients for SAHN and to minimize foreseeable complications. For “critical type” humeri, an alternative surgical procedure should be considered.

Fluoroscopic Technique for Open Reduction and Internal Fixation of Proximal Humeral Fracture Using the Proximal Humeral Locking Plate: Proposal of “Plate” and “Screw” Views

Proximal humeral fractures are common injuries with increasing incidence, particularly in the aging population. Nondisplaced or minimally displaced fractures can be treated conservatively whereas surgical fixation is usually indicated in the cases of displaced fractures. Various surgical options have been used for treatment of these fractures. Good outcomes have been reported with use of the Proximal Humeral Internal Locking System (PHILOS plate; Synthes, Zuchwil, Switzerland) as the implant of choice. However many complications have been reported, including varus malalignment, excessive retroversion of the articular part of the humerus, penetration of screws, and avascular necrosis of the humeral head. Therefore, we have hypothesized that an inadequate intraoperative fluoroscopic assessment may be an important factor contributing to these complications. We have described a step-by-step intraoperative fluoroscopic setup, including the proposal of a plate and screw view, focusing on the accuracy of reduction and proper placement of the PHILOS plate to prevent the complications previously described.

Surgical Technique for Open Reduction–Internal Fixation of an Unstable Displaced 3-Part Proximal Humeral Fracture Using a Proximal Humeral Locking Plate

The proximal humeral locking plate (PHLP) is a recently developed fixed-angle implant that is an option for open reduction–internal fixation of an unstable displaced proximal humeral fracture. Various articles have reported successful outcomes using the PHLP when compared with other implant designs. However, many complications still occur with use of the PHLP, such as avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration. These complications are related to the difficulty in fixation of this particular type of fracture, as well as ineffective surgical technique. We have therefore proposed a step-by-step surgical technique for open reduction–internal fixation of an unstable displaced 3-part proximal humeral fracture using a PHLP. This technique focuses on the precise placement of the PHLP according to the plate design, as well as an effective intraoperative assessment, to improve surgical outcomes and prevent the various complications of proximal humeral fractures.

Curative effect of anatomic plate internal fixation for complex proximal humeral fractures combined with humeral shaft fractures

Objective To investigate the efficacy of anatomic plate internal fixation in treatment of complex proximal humeral fractures combined with humeral shaft fractures. Methods This retrospective case series study included 58 patients with complex proximal humeral fractures combined with humeral shaft fractures admitted from July 1998 to July 2015. There were 31 males and 27 females, with a mean age of 63 years (range, 18-86 years). According to the Neer classification of proximal humeral fractures, three-part fractures were noted in 42 patients and four-part fractures in 16 patients. Four patients were combined with compressed or splitting fractures of the head of humerus and 38 patients with dislocation of the shoulder. According to the site classification of femoral shaft fractures, proximal 1/3 shaft fractures were noted in 36 patients, middle and distal 1/3 shaft fractures in 19, and multisegmental shaft fractures in three. All patients underwent anatomic reduction and anatomic plate internal fixation. Bone healing, Neer score of function outcome and complications were evaluated after operation. Results Mean duration of follow-up was 8.6 years (range, 1-18 years). Bone union was observed in all patients after 10 to 24 weeks (mean, 14.5 weeks). According to the Neer score, the outcomes were excellent in 23 patients, good in 25, fair in eight and poor in two, with the excellent rate of 83%. Complications such as infection, nerve injury and vascular injury were not observed after operation. Six patients suffered from limitations of shoulder anterior flexion and rise, one patient had humeral head necrosis and treated by shock wave treatment, and one patient had poor incision healing with hemorrhagic effusion and cured after dressing. Conclusion Anatomic plate internal fixation can contribute to fast functional recovery and few complications in treatment of complex proximal humeral fractures combined with humeral shaft fractures. Key words: Humeral fractures; Fracture fixation, internal; Reduction

How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction–internal fixation of proximal humeral fractures

With the introduction of the deltoid tuberosity index (DTI), a simple radiographic tool has become available to measure bone mineral density of the proximal humerus. The aim of this study was to assess the influence of local bone mineral density on the early failure rate after angular stable open reduction-internal fixation of proximal humeral fractures (PHFs). We retrospectively followed up all patients treated with angular stable implants for PHFs from 2007 to 2014. The fractures were classified according to Neer, and the DTI, metaphyseal head extension (MHE), medial hinge displacement, and quality of reduction were assessed. Failures were defined as head screw cutouts. The study included 146 patients (mean age, 66 years; range, 20-94 years). The mean follow-up period was 11 months (range, 3-94 months). Of the fractures, 91% were classified as 2- or 3-part fractures and 9% as 4-part fractures. The mean DTI was 1.44 (range, 1.19-2.11), and the mean MHE was 12 mm (range, 0-48 mm). The reduction result was at least acceptable in 80% of fractures. Screw cutouts were found in 23%. The DTI and MHE were the most significant preoperative predictors for the reduction result. The DTI (P = .036) and age (P = .02) were independent preoperative factors, and a good reduction (P = .001) was the only intraoperative factor influencing cutout. This study proves that good bone quality and a long MHE are helpful for the reduction. Furthermore, good bone quality, a younger age, and a good reduction prevent later cutout. We conclude that local bone quality is a relevant factor in the treatment plan for PHFs.

Paper #10 - Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial

Background: Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures. Methods: In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates. Results: There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow- up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672). Conclusion: Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group. Level of Evidence: Level I, Randomized controlled trial, Treatment study. Keywords: Randomized controlled trial; recovery of function; bone nails; bone plates; comparative study; shoulder fractures; postoperative complications.

Surgical treatment of complex proximal humeral fractures with a technique of nail and osteosuture: "NOS".

Open reduction and internal fixation of complex proximal humeral fracture represents a surgical challenge. The main objective of this procedure is to anatomically reduce the tuberosities. We propose a standardized and reproducible technique that we apply to all complex displaced 3- and 4-part fractures of patients under 50years. We use an antero-lateral trans-deltoid approach; the humeral head and the tuberosities are reduced under fluoroscopic control. The tuberosities are stabilized with an inter-tuberosity osteosuture, and we then introduce a thin and straight intra-medullary nail (Telegraph IV FH Orthopedics) at the hinge point of the humeral head. The osteosynthesis of the tuberosities is completed by 3- or 4-self-stable divergent screws in the nail. A dynamic distal locking stabilizes the humeral shaft in rotation and facilitates consolidation thanks to micro movements. The removal of the nail with an arthroscopic shoulder arthrolysis in case of stiffness is possible secondarily.

Proximal humerus fractures operated with PHILOS plate: 4 year prospective study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Fractures of proximal humerus are still an unsolved problem in many ways. Locked plating is becoming more common; precise knowledge of and experience with the surgical technique is required to maximize clinical outcomes. However the goal of proximal humerus fracture fixation should be stable reduction allowing early mobilization. This study is conducted to study the results and complications of proximal humeral fractures treated by anatomic locking compression plate (PHILOS- proximal humerus interlocking system) and PHLP- Pro.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a 4 year prospective study, conducted in the department of Orthopaedics in Shri B M Patil Medical College &amp;amp; Hospital, Vijaypur. Displaced two part, three part and four part fractures of proximal humerus with or without shoulder dislocation including fractures involving osteopenic bone were included.&lt;span&gt; The functional assessment was done according to constant Murley score and DASH score at the end of 6 months&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Out of 60 patients, 56 were available for follow-up: 24 patients having excellent results (4 are 2 part, 20 are 3 part fractures), 32 patients having good results (22 are 3 part, 10 are 4 part fractures). None of the patients had fair or poor results&lt;span lang="EN-IN"&gt;. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; In conclusion, the internal fixation of proximal humeral fractures with the use of anatomic locking compression plates yields reliable results when utilized correctly. We believe that, provided the correct surgical technique is used by competent surgeon, the anatomic locking compression plate is suitable for the stabilization of proximal humeral fractures and can lead to a good functional outcome&lt;span lang="EN-IN"&gt;.&lt;/span&gt;&lt;/p&gt;

Assessment of the restriction of arm elevation after intramedullary fixation for proximal humeral fractures.

Nail protrusion is suspected as a reason for the restriction of arm elevation after antegrade nailing of proximal humeral fractures, although assessment of the restriction of the glenohumeral joint during arm elevation has been insufficient. In this retrospective study, 30 shoulders with proximal humeral fractures in 29 cases were treated with Polarus short nails (Acumed, Beaverton, OR, USA). At a mean final follow-up of 14 months, clinical outcomes, bony union, alignment including retroversion of the head and entry points of the nails were evaluated. The ability of a subject to achieve maximum elevation above the zero position was also evaluated. Constant and Japanese Shoulder Association scores were a mean (SD) of 54 (12) and 71 (8.9) points, respectively. Even though all cases achieved bony union without mal-alignment of the head and greater tuberosity height or protrusion of the nail at its entry point, only six subjects could achieve maximum elevation above the zero position. Based on these findings, treatment of proximal humeral fractures with an antegrade humeral nail inserted from the top of the humeral head results in restricted arm elevation, even in patients without nail protrusion or fragment malalignment.

Numerical investigation of fracture impaction in proximal humeral fracture fixation with locking plate and intramedullary nail.

Fracture impaction is a surgical technique used to support the fractured humerus with locking plate or intramedullary nail when treating proximal humeral fractures. However, few studies have investigated the mechanical difference between fracture impaction with locking plate and with intramedullary nail. The mechanism of fracture impaction to increase stability is still unclear. The aim of this study was to use numerical methods to compare the biomechanical effect of treating proximal humeral fracture. Six different humerus models, including intact and fractured humeri with various fixation patterns were used in this study. Fracture impaction was simulated by moving the distal fragment of the humeral shift upwards directly until touching the inferior surface of the proximal fragment. We also considered both poor- and normal-quality bone in the simulation. Results confirmed that fracture impaction increases fracture stabilityand decreases peak stress in both implant and bone. Also, fracture impaction and plating with medial shift of the humeral shaft provides the highest stability. The metallic implant shared loading with the bone in the impacted models, while implants sustained all the loading alone in the nonimpacted models. Based on the results, the technique of fracture impaction is suggested for both nail and plate to reduce stresses on bone and implants and to increase structural stability. Furthermore, impaction with medial shift of the humeral shaft with plate is found to achieve the highest stability when treating proximal humeral fractures.

Avaliação ultrassonográfica do manguito rotador após a osteossíntese de fraturas da extremidade proximal do úmero com haste intramedular bloqueada

ObjectiveTo evaluate supraspinatus tendon integrity with ultrasound (US) in patients submitted to proximal humeral fracture (PHF) fixation with a locking intramedullary nail. MethodsThirty‐one patients with PHF treated with curvilinear locking intramedullary nail, aged between 50 and 85 years, were assessed by US at six months postoperatively and clinically at six and 12 months postoperatively. The primary aim was supraspinatus tendon integrity, evaluated by US at six months postoperatively. Secondary aims included the Constant‐Murley, DASH score, and visual analog pain scores, as well as complications and reoperation rates. ResultsFull‐thickness rotator cuff ruptures were observed in four patients (13%), supraspinatus ruptures in three cases (10%), and subscapularis ruptures in one case (3%). Partial ruptures were diagnosed in ten cases (32%). The results using the Constant‐Murley score at 12 months were 71.3±15.2 points for the entire series, with 73.2±16.1 points for patients without rotator cuff ruptures and 68.7±14.1 points for those with partial or complete ruptures, without a statistically significant difference (p=0.336). Complications, exclusively for rotator cuff ruptures, were observed in nine patients (29%). ConclusionA high rate of rotator cuff ruptures was demonstrated, with partial ruptures in 32% of cases and full‐thickness ruptures in 13%. However, clinical results are satisfactory, and are not influenced by the presence of rotator cuff ruptures.

Septic Arthritis of the Shoulder with Proximal Humerus Osteomyelitis, Treated by Ilizarov Shoulder Arthrodesis.

Septic arthritis of the shoulder can destroy the glenohumeral joint resulting in significant pain, instability and poor function. Surgical treatment is notoriously difficult with significant risk of complications. Shoulder arthrodesis has been performed using both internal and external fixation but has high complication rates in the presence of infection.We present our experience of managing a patient with significant pain and loss of function as a result of septic arthritis of the shoulder following infected proximal humeral fracture fixation with associated proximal humeral osteomyelitis. We discuss patient presentation, appropriate investigations, decision-making, pre-operative planning and the principles of managing of bone and joint infection.Wide excision with Ilizarov stabilisation and implantation of an absorbable antibiotic carrier, allowed successful fusion with eradication of the infection. The benefits of using this arthrodesis technique include reduced risk of infection recurrence and excellent stability of construct, therefore reducing time to fusion and minimising soft tissue trauma with the opportunity for early rehabilitation and return to optimal level of function.

Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings

Axillary nerve injuries after shoulder surgery are rare. In most studies, the frequency of injury is usually determined using clinical examinations, but results from intraoperative neuromonitoring studies have revealed higher than expected rates. Few studies have investigated this topic. Our aim was to determine the frequency of axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures by using electrophysiological assessments and to provide a review of the relevant literature. This was a retrospective cohort study of 76 consecutive patients who received open reduction and internal fixation of a proximal humeral fracture using a locking plate through a deltoid-splitting approach. We performed a clinical and electrophysiological examination at a minimum follow-up time of 12 months. Functional results were assessed according to the Constant-Murley and Disabilities of the Arm, Shoulder and Hand scores. Electrophysiological examinations comprised electromyography, electroneurography, and motor and somatosensory evoked potentials. The main outcome was the frequency of axillary nerve lesions. Forty patients were monitored for an average of 28 months. The mean raw Constant-Murley score was 61 points, the age- and gender-adjusted score was 71%, and the mean Disabilities of the Arm, Shoulder and Hand score was 33 points. Neurapraxia occurred in 1 patient, axonotmesis with incomplete reinnervation occurred in 3, and complete reinnervation occurred in 3. The latter group was classified as having a temporary axillary nerve lesion. The 10% rate of permanent axillary nerve lesions in our cohort is higher than expected based on the clinical examination. Electrophysiological assessment is therefore more appropriate to detect axillary nerve injuries.

Results of Proximal Humeral Fracture Fixation with Anatomical Locking Compression Plate using 6 stepwise Intraoperative Criteria in Surgical Procedures: A Retrospective Study.

OBJECTIVE: To report functional and radiological outcomes of open reduction andinternal fixation of proximal humeral fracture with anatomical LCP using 6 stepwiseintraoperative criteria in surgical procedures. MATERIALS AND METHODS: A total of 30 proximal humeral fractures whichwere treated with open reduction and internal fixation with anatomical LCP ofproximal humerus at a Level 1 and a Level 2 trauma center between January 2012 toDecember 2015 were collected. All patients were operated using the sametechnique in the supine position on a radiolucent table. The surgical approach was deltopectoralapproach. The operation was strictly done following 6 stepwise intraoperativeprocedures, this included: Step 1) reduction and fixation of head fragments. Thereference image in the true AP fluoroscopic view named “beetle car” appearance wasapplied in all cases; Step 2) plate positioning with the humeral head, according torecommendation of implant surgical instructions; Step 3) fix the plate to the humeralhead; Step 4) plate positioning to the shaft; Step 5) fix the shaft to the plate includingadditional locking head screws, head and calcar fixation and; Step 6) secure the suturesof the cuff to the plate. All patients received a similar physical therapy program followinginternal fixation. According to the Neer’s classification, there were 13 two-partfractures, 12 three-part fractures and 5 four-part fractures. The functional outcomes,Constant scores, and radiological outcomes (head-shaft angle and complications) wereanalyzed. The mean follow-up time was 18 months.RESULTS: At the end of the follow-up period, all fractures united with acceptablealignment. The mean Constant score for the injured side was 86 points (range 42–92).Head-shaft angle minor varus (115-124) in 5 patients, normal (125-145) 22, minor valgus(146-155) 1 and major valgus (>155) in 2 patients. 2 patients (6.6 %) had complicationswhich was confirmed by radiologic assessment. It was also found that one case hadsecondary intraarticular screw penetration and another had secondary varus duringfollow up. Both of the cases had severe osteoporosis, but no reoperation was required. CONCLUSION: This study reports on the functional and radiological outcomes ofopen reduction and fixation of displaced proximal humeral fracture with anatomicallocking compression plate using these developed 6 stepwise operative procedureswhich showed reasonable good to excellent outcomes with low complications. Thisstudy strongly suggested that the 6 stepwise surgical procedures should be strictlyfollowed in the correct order as a surgical strategy to prevent complications arisingfrom the operative technique of internal fixation of the complex proximal humeralfracture. from the operative technique of internal fixation of the difficult proximal humeralfracture.

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

Avascular necrosis (AVN) of the humeral head is a devastating complication of proximal humeral fracture (PHF) that often results in long-term morbidity for the patient. Rates of AVN depend on the number of fracture fragments and are highly variable. The literature suggests that timely stable and anatomic reduction may decrease the rate at which AVN develops after PHF. To our knowledge, there is no literature published investigating a temporal relationship between the timing of PHF fixation and rates of AVN. Operative records of one orthopedic trauma surgeon were used to identify patients that underwent open reduction internal fixation for PHF at our institution between 2007 and 2012. Radiographs at presentation were reviewed and used to classify the fractures into two, three or four parts. Date and time of the initial radiograph were recorded as were the date and time of available intra-operative fluoroscopic images. The time from presentation radiograph to operative fixation was calculated (hours). Available follow-up plain films were then reviewed and evaluated for the presence or absence of humeral head AVN. Time to surgery (less than or greater than 72h) and patient age did not correlate with development of AVN after PHF (p>0.26). Notably, the number of fracture fragments did influence the rate of AVN identified in patients with PHF (p=0.002). Early operative intervention does not appear to decrease the rate of development of avascular necrosis after PHF.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly

Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial

Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures. In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates. There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672). Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.

Complications of locked plating for proximal humeral fractures—are we getting any better?

Complication rates reported after locking plate fixation of proximal humeral fractures still range up to 40%. Whether modifications of surgical techniques, use of primary shoulder arthroplasty, or a fracture-specific management resulted in decreased complication rates during recent years remains unclear. Therefore, the aim of this long-term observation study was to analyze the incidence of complications and revision surgery after locked plating. Between February 2002 and December 2013, 788 patients (aged 67.4 ± 17.3 years) with displaced proximal humeral fractures were treated with locking plate, primary hemiarthroplasty (HA), or reverse shoulder arthroplasty (RSA). Standardized follow-up included radiographs at 1 day, 6 weeks, and 3, 6, and 12 months. Complications and unplanned revision surgery were prospectively recorded over the complete follow-up. Of 788 patients, 646 (82%) were treated with locking plate, 82 (10.4%) with HA, and 60 (7.6%) with RSA. Mean follow-up was 14.8 ± 3.8 months. The mean complication rate associated with locked plating was 12.8%, and revision surgery was necessary in 11.6%. Within the last 5 years, the loss of fixation rate markedly decreased from 14.3% to 4.8%; simultaneously, an increased use of RSA was observed. The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. Among others, this might be due to an increased use of primary RSA for complex fracture types. In addition to a precise surgical technique, choosing the adequate treatment for each individual fracture to avoid complications and revision surgery is of utmost importance.