Fixation Of Proximal Humeral Fractures Research Articles

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.

Biomechanical effect of the configuration of screw hole style on locking plate fixation in proximal humerus fracture with a simulated gap: A finite element analysis

BackgroundLocking plate fixation for proximal humeral fractures is a commonly used device. Recently, plate breakages were continuously reported that the implants all have a mixture of holes allowing placement of both locking and non-locking screws (so-called combi plates). In commercialized proximal humeral plates, there still are two screw hole styles included “locking and dynamic holes separated” and “locking hole only” configurations. It is important to understand the biomechanical effect of different screw hole style on the stress distribution in bone plate. MethodsFinite element method was employed to conduct a computational investigation. Three proximal humeral plate models with different screw hole configurations were reconstructed depended upon an identical commercialized implant. A three-dimensional model of a humerus was created using process of thresholding based on the grayscale values of the CT scanning of an intact humerus. A “virtual” subcapital osteotomy was performed. Simulations were performed under an increasing axial load. The von Mises stresses around the screw holes of the plate shaft, the construct stiffness and the directional displacement within the fracture gap were calculated for comparison. ResultsThe mean value of the peak von Mises stresses around the screw holes in the plate shaft was the highest for combi hole design while it was smallest for the locking and dynamic holes separated design. The stiffness of the plate-bone construct was 15% higher in the locking screw only design (132.6N/mm) compared with the combi design (115.0N/mm), and it was 4% higher than the combi design for the locking and dynamic holes separated design (119.5N/mm). The displacement within the fracture gap was greatest in the combi hole design, whereas it was smallest for the locking hole only design. ConclusionsThe computed results provide a possible explanation for the breakages of combi plates revealed in clinical reports. The locking and dynamic holes separated design may be a better configuration to reduce the risk of plate fracture.

Fosfato β-Tricálcico Monobloco no Tratamento de Fraturas Proximais do Úmero Cirúrgicas

<p><strong>Introduction:</strong> The proximal humeral fractures are becoming more frequent, with a greater tendency for its surgical treatment by osteosynthesis with plate and locked screws. The mechanical and biological failure in these fractures and devices, despite the evolution of this type of implants, highlighted the synthetic bone grafts became an option.<br /><strong>Material and Methods:</strong> Over a period of 96 months, patients considered were those with proximal humeral fractures treated surgically with a plate and locked screws, and in which β-tricalcium phosphate bone graft had been used. Functional results were evaluated by the shoulder range of motion as the radiological results.<br /><strong>Results:</strong> In 19 patients, with a medial follow up of 53 months, we obtained an average shoulder range of motion of 140º in abduction, 142º in forward flexion, 37º in external rotation and L3 hand position in internal rotation for a cefalo-diaphyseal angle of 136º.<br /><strong>Discussion:</strong> The β-tricalcium phosphate synthetic bone graft allows the maintenance of reduction after fixation of proximal humeral fractures stabilized with plate and locked screws. This reduction which means the maintenance of cefalo-diaphyseal angle is in close relationship with functional results as shown by shoulder range of motion in all planes.<br /><strong>Conclusion:</strong> The β-tricalcium phosphate synthetic bone graft should be seen as an adjuvant therapy in extramedullary fixation of proximal humeral fractures, especially those with greater comminution of the medial calcar.</p>

β-Tricalcium Phosphate in the Surgical Treatment of Proximal Humeral Fractures

The proximal humeral fractures are becoming more frequent, with a greater tendency for its surgical treatment by osteosynthesis with plate and locked screws. The mechanical and biological failure in these fractures and devices, despite the evolution of this type of implants, highlighted the synthetic bone grafts became an option. Over a period of 96 months, patients considered were those with proximal humeral fractures treated surgically with a plate and locked screws, and in which β-tricalcium phosphate bone graft had been used. Functional results were evaluated by the shoulder range of motion as the radiological results. In 19 patients, with a medial follow up of 53 months, we obtained an average shoulder range of motion of 140º in abduction, 142º in forward flexion, 37º in external rotation and L3 hand position in internal rotation for a cefalo-diaphyseal angle of 136º. The β-tricalcium phosphate synthetic bone graft allows the maintenance of reduction after fixation of proximal humeral fractures stabilized with plate and locked screws. This reduction which means the maintenance of cefalo-diaphyseal angle is in close relationship with functional results as shown by shoulder range of motion in all planes. The β-tricalcium phosphate synthetic bone graft should be seen as an adjuvant therapy in extramedullary fixation of proximal humeral fractures, especially those with greater comminution of the medial calcar.

Fixation of complex proximal humeral fractures in elderly patients with a locking plate: A retrospective analysis of radiographic and clinical outcome and complications

PurposeThe optimal surgical treatment of displaced type B and C fractures of the proximal humerus in the elderly remains controversial. Good clinical results have been reported by plating these fractures as well as a high rate of complications. Our retrospective study aims to evaluate clinical recovery and complications using the S3 locking plate in elderly patients. MethodsFifty-one patients older than 65 years of age, with a complex proximal humeral fracture type B or C (AO classification system), were included. Patients have been followed up for a minimum of 12 months. We assessed callus formation, radiological results, clinical outcome (according to the Constant Shoulder Score System) and complications. Any difference in the clinical recovery among the 2 types of fracture pattern (B and C) was investigated. ResultsThe mean time of fracture healing was 12.4 weeks. The mean Constant score at 3, 6 and 12 months was 68, 73 and 75 respectively. No statistically significant difference in the clinical outcome was observed between the B and C fracture patterns (p > 0.05). We noticed an overall of 5 complications (9.8%). There was no need to revision any of the implants. ConclusionAnatomic reduction and proper plate positioning are essential for minimizing implant-related complications. In our experience the S3 angular stability system offers a proper osteosyntesis and a good clinical recovery with a low rate of complications.

Factors influencing the effect of locking plate fixation in proximal humeral fractures of the elderly

Background: Curative effect following the locking plate fixation of proximal humeral fractures in the elderly have been inconsistent, factor that contributes to the outcomes remains unknown. This study aims to analyse the factors influencing the curative effect of locking plate fixation in proximal humeral fractures of the elderly. Methods: A retrospective analysis was conducted for 72 elderly patients of proximal humeral fractures who had been treated from January 2010 to August 2013. Among the patients, 26 were male and 46 were female. The patients’ age ranged from 60 years old to 78 years old, with an average age of 70.2 years. Constant score was used as clinical outcome measure. Gender, fracture type, plate position, varus of the head-shaft angle, associated injury, and the time to begin functional training after operation were identified as prognostic factors. Results: The patients were followed up for 18 months to 48 months with a mean period of 30.4 months. The constant score ranged from 33 to 91, with an average of 79.1. Shoulder joint function had a significant correlation with fracture type, plate position, and varus of the head-shaft angle. No significant difference was found between shoulder joint function and gender, associated injury, and the time to begin functional training after operation. Conclusions: Fracture type, plate position, and varus of the head-shaft angle were key factors affecting the shoulder function after operation.

Anatomical and biomechanical evaluation of an intramedullary nail for fractures of proximal humerus fractures based on tuberosity fixation

BackgroundFor unstable proximal humerus fractures, both plates and nails may be recommended. We introduce an anterograde nail designed for the treatment of 3- and 4-parts proximal humerus fractures. The aim of this study is to compare the biomechanics of this nail versus a plate and then to analyze the relationships of the screws with the axillary nerve. Our working hypotheses are as follows: (1) this nail is biomechanically equal or better to the reference plate and (2) it does not endanger the axillary nerve. MethodsBiomechanical study: using 40 sawbones, a reproducible 4-part fracture was created and fixed first with an angle-stable plate for proximal humeral fracture, then fixed with the nail using 2 posterior screws. All specimens were mounted in a custom testing apparatus. Two trails were performed needing each time 5 “normal” and 5 “osteoporotic” bones. Anatomical studyOn 20 unpaired shoulders, a nail was inserted with all screws through a superior approach (deltoid split approach). Dissection of all shoulders was done to identify the axillary nerve. The distance between each screw and the axillary nerve or its branches was measured. FindingsThe proximal humerus nail demonstrated higher values than locking plate for both stiffness and load to failure. The failure mode differs in function of the type of osteosynthesis.The lowest distance between a screw and the axillary nerve was 20.13mm. InterpretationsWe introduce a biomechanically efficient nail without increased neurological risks to improve the pullout strength of the screws to provide more secure fixation of proximal humeral fractures. Level of evidenceBasic Science Study, Anatomic Cadaver Study.

Timing of surgery for open reduction and internal fixation of displaced proximal humeral fractures

BackgroundOpen reduction and internal fixation is one established method for treatment of displaced fractures of the proximal humerus. However, the timing of surgery and its effect on complications have not yet been investigated in the literature. Hence, aim of this study was to analyze the occurrence of complication following locked plating of proximal humeral fractures when surgery was delayed in comparison to early intervention. MethodsBetween February 2002 and November 2010, 497 patients with displaced proximal humeral fractures were treated by open reduction and locked plating. 329 patients were available for follow-up with a minimum of 12 months after surgery. Outcome analysis included radiographic evidence of loss of fixation (>10° of secondary displacement), screw-cutout and avascular head necrosis. Outcomes were analyzed with regards to age, gender and fracture pattern and were compared between time intervals in which the primary surgery had been conducted; early intervention (<48h), timely scheduled for surgery (3–5 days) and delayed intervention (>5 days). ResultsOf 329 patients (68.4% women; median age at time of surgery: 69.9 years, 95% Confidence Interval (CI) 68.2, 71.2) the median time between fracture incident and surgical intervention was 3.2 days (95%CI: 3.1, 3.3). Surgery was performed in a 2-part fracture at a median of 3.3 days (95%CI: 3.2, 3.4) after trauma, in a 3-part fracture after 3.3 days (95%CI: 3.1, 3.4), in a 4-part fracture 2.9 days (95%CI: 2.8, 3.0), in head split type fracture 2.2 days (95%CI: 2.0, 2.4) and in dislocation type fracture 0.8 days after trauma (95%CI: 0.7, 0.9, p = 0.40). Loss of fixation was observed in 12.8% (n = 42 patients), of which in 4.9% (n = 16) screw cutout was evident and in 6.8% of cases (n = 20) avascular head necrosis was diagnosed. Patients in which complication was observed were treated at median 2.5 days after trauma (95% CI, 1.8, 3.2), in comparison, patients without evidence of complications were treated at a median of 3.2 days (95% CI, 2.8–3.8, p = 0.35). The odds ratio regarding occurrence of complications for patients treated <48 hours was 0,924, for patients in which surgery was performed 3–5 days after the incident the odds ratio was 0,836 and in patients treated > 5 days the odds ratio was 1,637. ConclusionsLoss of fixation following open reduction and internal fixation of proximal humeral fractures was not more frequently observed when surgery was performed 3–5 days after the incident in comparison to early intervention (<48h). However, a delay of intervention > 5 days is related to significant increase of complications. Thus, if open reduction and internal fixation is indicated, reconstruction of the proximal humerus should be performed within 5 days of the fracture event. In head split and dislocated fracture types anatomic reconstruction completed within 48h from the incident may be beneficial with regards to risk of avascular necrosis.

Application of Additional Medial Plate in Treatment of Proximal Humeral Fractures With Unstable Medial Column: A Finite Element Study and Clinical Practice.

The purpose of this study was to use finite element analysis to compare the biomechanical characteristics after lateral locking plate (LLP) or LLP with a medial anatomical locking plate (LLP-MLP) fixation of proximal humeral fractures with an unstable medial column.First, a 3-dimensional, finite element analysis model was developed. Next, LLP and LLP-MLP implants were instrumented into the proximal humeral fracture models. Compressive and rotational loads were then applied to the humerus model to determine the biomechanical characteristics. Both normal and osteoporotic proximal humerus fractures were simulated using 2 internal fixation methods each under 7 loading conditions. To assess the biomechanical characteristics, the construct stiffness, fracture micromotion, and stress distribution on the implants were recorded and compared.The LLP-MLP method provided both lateral and medial support that reduced the stress on the LLP and the amount of displacement in the fracture region. In contrast, the LLP method resulted in more instability in the medial column and larger magnitudes of stress. In osteoporotic bone, the LLP was more inclined to fail than LLP-MLP.The LLP-MLP method provides a strong support for the medial column and increases the stability of the region surrounding the fracture.

Significant differences between local reporting and central assessment of radiological complications in a prospective, multicenter study about locking plate fixation of proximal humerus fractures.

To compare radiological complication reporting outcomes undertaken by an independent review board and the responsible on-site study personnel in a multicenter study about locking plate fixation of proximal humeral fractures. prospective, multicenter study SETTING:: Level I trauma centers PATIENTS:: One-hundred and fifty patients with a radiological confirmed, closed, displaced proximal humeral fracture fixed with a locking plate and aged between fifty and ninety years. Re-evaluation of all radiological data according to pre-defined criteria after finished collection of all study radiographs by an independent review board. Differences in outcomes between the review board and the sites assessment were tested with a paired t-test. Inter-rater agreements between the central review board and sites assessments were estimated by means of kappa statistics. The review board revealed significant more radiological complications than the sites assessment (p = 0.006), except for the complication 'head necrosis'. The inter-rater agreement was slight to moderate in all calculated categories. To prevent underreporting of radiological complications by on-site assessment, the implementation of a complication review board, using pre-defined criteria, is recommended for clinical studies that focus on radiological complications.

Locked Plate Fixation of Proximal Humeral Fractures Through an Extended Deltoid Split Approach with Use of a Shoulder Strap Incision.

The shoulder strap approach involves an anterolateral deltoid split with use of an inverted U incision, providing excellent lateral exposure for locked plate fixation of complex proximal humeral fractures. Proper positioning of the image intensifier is important for uninterrupted fluoroscopy. The tip of the acromion is a useful landmark and serves as the proximal extent of the incision. Raise a broad-based full-thickness fasciocutaneous flap. Split the deltoid anteriorly to minimize the chances of denervation. Leave a cuff of deltoid muscle to protect the axillary nerve. The cuff sutures are helpful in reduction of the proximal fracture segments and improve stability of three and four-part fractures. Avoid varus reduction and reestablish the relationship between the humeral head and the greater tuberosity. Proper plate positioning is important to maximize the possibility of using all proximal screw options and to minimize chances of impingement. As is necessary with all locked internal fixators, reduce the fracture before fixing the plate; the order of fixation may vary with the type of fracture. In our study of fifty patients with a displaced three or four-part fracture treated with this approach, all flaps healed well without any necrosis and no infections were seen.IndicationsContraindicationsPitfalls & Challenges.

Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus.

We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate. To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes. Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier. The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury. The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like. After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate. Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities. Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval. Do not close the deltopectoral interval. As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol. In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures

Shear forces at the bone-implant interface lead to a loss of reduction after locking plate fixation of proximal humeral fractures. The aim of the study was to analyze the roles of medial support screws and screw augmentation in failure loads and motion at the bone-implant interface after locking plate fixation of proximal humeral fractures. Unstable 3-part fractures were simulated in 6 pairs of cadaveric humeri and were fixed with a DiPhos-H locking plate (Lima Corporate, Udine, Italy). An additional medial support screw was implanted in 1 humerus of every donor. The opposite humerus was stabilized with a medial support screw and additional bone cement augmentation of the 2 anteriorly directed head screws. Specimens were loaded in the varus bending position. Stiffness, failure loads, plate bending, and the motion at the bone-implant interface were evaluated using an optical motion capture system. The mean load to failure was 669 N (standard deviation [SD], 117 N) after fixation with medial support screws alone and 706 N (SD, 153 N) after additional head screw augmentation (P = .646). The initial stiffness was 453 N/mm (SD, 4.16 N/mm) and 461 N/mm (SD, 64.3 N/mm), respectively (P = .594). Plate bending did not differ between the 2 groups. However, motion at the bone-implant interface was significantly reduced after head screw augmentation (P < .05). The addition of bone cement to augment anteriorly directed head screws does not increase stiffness and failure loads but reduces motion at the bone-implant interface. Thus, the risk of secondary dislocation of the head fragment may be reduced.

Minimally invasive plate osteosynthesis for proximal humeral fractures.

To report the outcome after minimally invasive plate osteosynthesis (MIPO) through the deltoid-splitting approach for proximal humeral fractures. 10 men and 30 women aged 37 to 88 years underwent MIPO through the deltoid-splitting approach using the Proximal Humerus Internal Locking System or the Locking Proximal Humerus Plate for 2-part (n=18), 3-part (n=20), and 4-part (n=2) proximal humeral fractures. The rehabilitation protocol was standardised. All 40 patients were followed up at 3 months, 34 (85%) at 6 months, 30 (75%) at one year, and 13 (33%) at 2 years. Two patients had malunion. No patient had avascular necrosis, infection, nerve palsy, or nonunion. The mean Constant score at one year and 2 years was 75 and 87.5, respectively. The Constant score at 6 months correlated to that at one year (r=0.926, p<0.0001) and at 2 years (r=0.874, p=0.0001). In younger patients, improvement in the range of motion was faster. The early plateau group (those with no further improvement after 6 months) and the late plateau group (those with no further improvement after one year) did not differ significantly in age, fracture grade, or hand dominance. MIPO for fixation of proximal humeral fractures using a locking plate is safe and effective in enabling an early return of shoulder function.

Proximal humeral fracture fixation: multicenter study with carbon fiber peek plate.

Locking plate fixation is a reliable treatment for many displaced proximal humeral fractures. Carbon fiber-reinforced-poly-ether-ether-ketone (CFR-PEEK) plates have recently been introduced as an alternative to traditional metallic plates. In a multicenter study involving the Orthopedic Services of 6 Italian hospitals, 182 patients with a proximal humeral fracture were treated with a Diphos H (Lima Corporate, San Daniele del Friuli, Italy) CFR-PEEK plate, 160 of whom were followed clinically and radiographically for 2 years or more. Fractures were classified by Neer's system. The functional results were assessed by Constant and DASH scores. The average time to radiographic healing was 5.6 months in 158 of 160 cases. Mean Constant score was 76, and mean DASH score was 28 at 2 years. There were two nonunions (one septic and one aseptic) and 13 cases of partial (9) or massive (4) humeral head necrosis. In three of the 78 patients treated with the first-generation plates, hardware breakage happened during the operation and the plate was replaced. There was no failure among the cases treated with the thicker second-generation plate. In eight cases, there was a perforation of the humeral head by the cephalic screws. CFR-PEEK plates proved as reliable as metallic plates in the treatment of proximal humeral fractures. The advantages of these new devices include a better visualization of fracture reduction during intraoperative fluoroscopic assessment and easy hardware removal due to the absence of screw-plate cold fusion.

An Anterosuperior Deltoid Splitting Approach for Plate Fixation of Proximal Humeral Fractures

Background: The purpose of this study was to evaluate the usefulness and safety of the anterosuperior deltoid splitting approach for fixation of displaced proximal humeral fractures by analyzing the surgical outcomes. Methods: Twenty-three patients who could be followed-up for at least 8 months after the treatment of displaced proximal humeral fractures through the anterosuperior deltoid splitting approach were enrolled. We evaluated the reduction of the fractures and surgery-related complications at the last follow-up using X-ray results and clinical outcomes comprising the University of California at Los Angeles (UCLA) scoring system and the Korean Shoulder Society (KSS) score. Results: At the last follow-up of patients treated using the anterosuperior deltoid splitting approach for internal fixation of proximal humeral fractures, we found 22 cases (95.6%) of bone union, a mean UCLA score of 28.3 (range, 15 to 34) and a mean KSS score of 82.1 (range, 67 to 95). Various surgery-related complications were noted; a case of varus malunion after fracture displacement, a case of nonunion, a case of delayed union, two cases of impingement, and a case of partial axillary nerve injury, which recovered completely through the follow-up. Conclusions: Plate fixation using the anterosuperior deltoid splitting approach could be another reliable option for treating displaced proximal humeral fractures.

Biomechanical and range of motion analysis of two proximally fixed locking plate systems for fixation of proximal humeral fractures

Background: Locking plate constructs have become the implant of choice for operative fixation of proximal humeral fractures. Plating systems that are fixed proximally (<1 cm from the tip of the greater tuberosity) have yet to be compared to systems affixed distally (>1 cm). This study evaluated range of motion and load to failure of two commonly used proximal humeral locking plate systems. Methods: Six pairs of cadaver shoulders were divided into two groups (R [proximally fixed] and L [distally fixed]). Range of motion was evaluated fluoroscopically before and after plate implantation. Fixation was removed to create a surgical neck fracture using an oscillating saw and then replaced. Load to failure was conducted using a mechanical testing system to evaluate differences in the strengths of the constructs. Results: Shoulder range of motion did not decrease significantly after plate placement within each group (L, P=0.23; R, P=0.99). Range of motion was not statistically different between the groups prior to plate fixation (P=0.88) or after (P=0.60). Average load to failure for groups L and R were 1635±374 N and 1613±269 N, respectively, and were not statistically different (P=0.91). Primary modes of failure for groups R and L were plate bending and failure of distal fixation, respectively. Conclusions: Mechanical strength of the locking plate constructs and range of motion after plate placement do not differ significantly between the proximally or distally placed proximal humeral locking-plate systems tested.