Fixation Of Proximal Humerus Fractures Research Articles

Identifying clinically meaningful subgroups following open reduction and internal fixation for proximal humerus fractures: a risk stratification analysis for mortality and 30-day complications using machine learning

Identifying clinically meaningful subgroups following open reduction and internal fixation for proximal humerus fractures: a risk stratification analysis for mortality and 30-day complications using machine learning

Proximal humerus open reduction internal fixation with and without biceps tenodesis: assessment of early clinical outcomes

BackgroundThe role of biceps tenodesis (BT) during open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF) remains unclear. A subset of patients undergoing ORIF have persistent pain with unclear etiology. The purpose of our study was to compare outcomes of ORIF of proximal humerus fractures with and without concomitant biceps tenodesis (BT). We hypothesize patients undergoing biceps tenodesis at the time of ORIF will have improved patient-reported outcome scores with fewer secondary procedures related to treatment of the biceps. MethodsIn this retrospective cohort study, all patients undergoing ORIF for a PHF at a single level one trauma center from January 2019 to June 2022 were reviewed. Patients under the age of 18 were excluded. Primary outcomes were PROMIS physical function, depression, and pain interference scores at 5 time points up to final follow-up. Secondary outcomes included total operative time, complications, subsequent procedures, steroid injections, and range of motion. Chi-square tests were performed for categorical values and paired t-tests for continuous variables. Results71 patients met inclusion criteria: 41 undergoing ORIF without BT, and 30 undergoing ORIF with BT. Average follow-up was 11 months. There were no statistically significant differences in patient demographics between groups. There were no differences in PROMIS scores at any time point postoperatively. At final follow-up patients in the ORIF with BT group had higher forward flexion than those who did not undergo BT (142 vs. 123 degrees, respectively, p < .02). There were no differences in surgical time, revision rates, postsurgical complications, or postoperative injections between groups. ConclusionBiceps tenodesis performed during ORIF of PHFs did not result in significantly different functional or patient-reported outcomes between groups, except for greater forward flexion at final follow-up. Although BT was done more commonly in severe PHFs, patients in both groups had similar rates of subsequent biceps-related procedures and revision surgery.

Functional Outcomes of Open Reduction and Internal Fixation in Proximal Humerus Fractures by Philos Plate

INTRODUCTION Proximal humerus fractures are one very common and usually occur in elderly people. These fractures are usually associated with some degree of comminution and deformity. Therefore, good anatomical reduction of fracture fragments and early mobilization are the main component for optimal outcomes of involved limb. This study was intended to evaluate the functional outcome of proximal humerus fracture in adults managed by open reduction and internal fixation (ORIF) by proximal humerus interlocking osteosynthesis (PHILOS) plate. MATERIAL AND METHODS This prospective and observational hospital based study was carried out in Orthopedics Department of Universal College of medical Sciences-Teaching Hospital (UCMS-TH) from October 2021 to September 2023. All patients with proximal humerus fractures who fulfilled the inclusion criteria and who underwent open reduction and internal fixation by PHILOS plate were enrolled in the study. Functional outcome was assessed according to Constant murley scoring system and Visual analogue score. Post-operatively patients were regularly followed at 6 weeks, 3 months and 6 months. RESULTS In this study of 60 cases, the mean age group was 55.38±11.40 years and male patients outnumbered female patients (39 males and 21 females). 36 cases (60%) were of right side and 24 (40%) were of left side. Majority of the fractures were due to fall injury (57%) followed by road traffic accident (35%). The mean Constant Murley Score was 78.15±5.620 and VAS (visual analogue score) was 1.88±0.865. CONCLUSION Open reduction and internal fixation by PHILOS plate is an effective procedure providing good anatomical restoration and early mobilization in proximal humerus fracture thus providing good functional outcome.

Postoperative Opioid Dependence in Patients Undergoing Either Total or Reverse Shoulder Arthroplasty for Proximal Humerus Fracture Fixation.

In elderly patients who have proximal humerus fractures, treatment commonly involves total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). Following these procedures, patients often require opioids for postoperative analgesia. This common scenario is of clinical and societal importance, as increased postoperative opioid usage has been shown to worsen outcomes and increase the likelihood for dependence. We aimed to compare postoperative opioid use in patients undergoing either TSA or RSA for fixation of their proximal humerus fracture. Specifically, we assessed: (1) postoperative opioid use at two, four, six, eight, and greater than eight weeks postoperatively; (2) aseptic revision rates at 90-days, one year, and two years postoperatively; and (3) periprosthetic joint infection (PJI) rates at 90-days, one year, and two years postoperatively between patients undergoing TSA or RSA for the surgical management of their proximal humerus fractures. For this review, we queried a national all-payer database from October 1, 2015 to October 31, 2020 (n=1.5 million) for all patients who had a "proximal humerus fracture" diagnosis who underwent either TSA or RSA. There were two cohorts: patients undergoing TSA (n=731) and patients undergoing RSA (n=731). Bivariate Chi-square analyses. We found no differences (p>0.05) in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA after two weeks. There was not a significant difference in aseptic revision or PJI rates between the two cohorts (all p>0.05). The evidence comparing opioid use in patients undergoing either TSA or RSA for proximal humerus fracture fixation is lacking. Our study specifically showed no differences in opioid use postoperatively in patients undergoing RSA for proximal humerus management compared to patients undergoing TSA.

Predictors of Extended Length of Stay Following Open Reduction and Internal Fixation for Proximal Humerus Fractures

An extended length of stay following open reduction and internal fixation (ORIF) for proximal humerus fractures (PHFs) is associated with increased patient morbidity and health care costs. The primary purpose of this study was to identify risk factors for an extended length of stay following ORIF for PHF. All patients who underwent ORIF for PHF between 2015 and 2021 were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patient demographics, comorbid conditions, and postoperative complications within 30 days of procedure were collected. Extended length of stay (eLOS) was defined by ≥ 3 days from operation to discharge. Multivariate logistic regression was employed to identify predictors of eLOS following ORIF. Characteristics of patients significantly associated with eLOS included age ≥ 75 years (p < .001), male gender (p < 0.001), body mass index (BMI) < 18.5 (P= .001), American Society of Anesthesiologists (ASA) classification ≥ 3 (P < .001), dependent functional status (P < .001), noninsulin-dependent diabetes (P= .037), insulin-dependent diabetes (P < .001), chronic obstructive pulmonary disease (P < .001), congestive heart failure (CHF) (P < .001), hypertension (P < 0.001), dialysis (P < .013), disseminated cancer (P < 0.001), chronic steroid use (P= .004), and bleeding disorder (P < .001). Independent predictors of eLOS were age ≥ 75 years (OR= 2.69; P < .001), BMI < 18.5 (OR= 1.70; P= .016), ASA ≥ 3 (OR= 2.70; P < .001), dependent functional status (OR= 2.30; P < .001), CHF (OR= 3.57; P < .001), disseminated cancer (OR= 7.62; P < .001), and bleeding disorder (OR= 2.68; P < .001). Age ≥ 75, BMI < 18.5, ASA ≥ 3, functional dependence, CHF, disseminated cancer, and bleeding disorder were independently associated with eLOS. Assessing specific patient factors prior to ORIF for PHF can assist in managing perioperative risks and decreasing expenses related to eLOS. Prognosis III.

Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis.

Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF). A systematic search of the literature was undertaken using the Medline®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted. A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group. This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Biomechanical evaluation of novel intra- and extramedullary assembly fixation for proximal humerus fractures in the elderly.

Purpose: A novel intra- and extramedullary assembly fixation method was introduced, which achieved good clinical results in complex proximal humeral fractures; however, evidence of its comparability with traditional fixation is lacking. This biomechanical study aimed to compare it with traditional fixation devices in osteoporotic proximal humeral fractures. Methods: Three-part proximal humeral fractures with osteopenia were created on 12 pairs of fresh frozen humerus specimens and allocated to three groups: 1) lateral locking plate, 2) intramedullary nail, and 3) intra- and extramedullary assembly fixation. The specimens were loaded to simulate the force at 25° abduction. Thereafter, an axial stiffness test and a compound cyclic load to failure test were applied. Structural stiffness, number of cycles loaded to failure, and relative displacement values at predetermined measurement points were recorded using a testing machine and a synchronized 3D video tracking system. Results: In terms of initial stiffness and the number of cycles loaded to failure, the intra- and extramedullary assembly fixation group showed notable improvements compared to the other groups (p <0.017). The mean relative displacement value of measurement points in the intra- and extramedullary assembly fixation group was smaller than that in the other two groups. However, there was no significant difference until 10,000 cycles. The mean relative displacement of the intramedullary nail group (3.136mm) exceeded 3mm at 7,500 cycles of loading. Conclusion: In this test model, axial fixation can provide better mechanical stability than non-axial fixation. The intra- and extramedullary assembly fixation is better able to prevent the varus collapse for elderly proximal humeral fractures with posteromedial comminution.

Dual-Plate Fixation for Proximal Humerus Fractures With Unstable Medial Column in Patients With Osteoporosis.

To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus fractures with medial column comminution and varus deformity in patients with osteoporosis. Retrospective. Academic medical center. Overall, 52 patients were enrolled. Of these, 26 patients underwent dual-plate fixation. The control group (LLP) was matched to the dual-plate group for age, sex, injured side, and fracture type. Patients in the dual-plate group were treated with LLP and medial buttress plate, whereas patients in the LLP group were treated with only an LLP. Demographic factors, operative time, and level of hemoglobin of the 2 groups obtained from medical records. Changes in the neck-shaft angle and the development of postoperative complications were recorded. Clinical outcomes were measured based on the visual analog scale; American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder, and Hand; and Constant-Murley scores. The operation time and hemoglobin loss did not differ significantly between the groups. Radiographic evaluation showed a significantly lower change in neck-shaft angle in the dual-=plate group than in the LLP group. The dual-plate group also showed better Disabilities of the Arm, Shoulder, and Hand; American Shoulder and Elbow Surgeons; and Constant-Murley scores than the LLP group. Fixation using additional medial buttress plate with LLP may be considered for treating proximal humerus fractures in patients with an unstable medial column, varus deformity, and osteoporosis. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of effectiveness of locking compression plates in internal fixation of proximal humerus fractures: a prospective study

Introduction: Locking compression plate (LCP) provides significant biological and biomechanical advantages in the management of proximal humerus fracture (PHF) by providing greater stability, vascular preservation, superior healing, and fewer complications. However, the translation of these properties to functional benefits for patients remains to be elucidated. The objective of the study was to evaluate the effectiveness of LCP in internal fixation of PHF in terms of rate of healing and functional outcomes. Method: This prospective study enrolled 30 Proximal Humerus Fracture patients aged &gt;18 years, from both genders, and treated them with LCP. They were followed up regularly for 1 year and assessed clinically and radiologically using Neer’s criteria and Constant-Murray score. Results were analysed using Chi-square test, p≤0.05 indicated statistical significance. Result: With a mean age of 45.20±15.02 y and M:F ratio of 2.3:1, most patients showed right-sided injuries 18(60%) and Neer 4-part injuries 13(43.33%), predominantly due to road traffic accidents 19(60%), with a satisfactory Neer’s score 26(86.67%) and a good Constant-Murray score 16(53.33%). The mode of injury showed significant association with age (p=0.013) but not with gender (p=0.866). Over follow up, 27(90%) patients maintained humeral head height and 24(80%) patients showed good humeral neck-shaft angle. Radiological union of PHF took 12 weeks in 12(43.33%) of patients with no dislocation in 27(90%) of patients. However, 1(3.3%) patient showed no union. Conclusion: LCP is associated with favorable clinical, functional and radiological outcomes in PHF patients by providing rapid healing and good rigidity, angular stability, and torsional strength.

Comparative study between deltoid split approach versus delto pectoral approach for proximal humerus fracture fixation

Background: Proximal humeral fracture is defined as fractures occurring at or proximal to the surgical neck of the humerus. It affects 2.4% of women over the age of 75 years. It is the commonest fracture affecting the shoulder girdle in adults and its incidence is rising. For displaced fractures that meet surgical indications, deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. Deltoid splitting approach offers advantages of better exposure and implant placement for fixation of the fracture and early mobilization of the shoulder joint. Methods: This is a comparative study of 30 cases of proximal humerus fractures treated by surgical fixation through deltoid splitting approach and 30 cases treated by delto pectoral approach. Patient of both sexes belonging to adult age group in general population presenting with proximal humerus fracture to the orthopaedic department of Bapuji Hospital and Chigateri General hospital attached to J.J.M. Medical College, Davangere. The period of survey extends from December 2020 to December 2022. The final results were evaluated using constant Murley score periodically. This constant Murley score ranges from 0 to 100 points representing worst and shoulder function respectively. Results: No statistically significant difference was observed in outcome with regard to mechanism of injury, side of fracture and type of fracture with both deltoid splitting approach and delto pectoral approach. Conclusions: The treatment of proximal humeral fractures with a proximal locking plate is reliable using both approaches. No significant difference found in functional outcome of proximal humerus fracture following deltoid split and deltopectoral approach on serial follow up.

Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement.

Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating. Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.

Fibular Autograft as Medial Support with Proximal Humerus Locking Plate Construct in Comminuted Proximal Humerus Fractures: A Retrospective Analysis.

Varus collapse is one of the pivotal mechanisms of failure following surgical fixation of proximal humerus fractures. The aim of the present study was to evaluate functional and radiological outcomes of non-vascularized fibular autograft as medial support with locking plate construct for comminuted proximal humerus fractures (PHF's). We retrospectively evaluated 18 patients with unstable PHF's in the age group 50-70years with a minimum follow-up of two years. All thefracture patterns were classified according to Resch, Neer's and AO classification and either medial calcar compromise or comminution were present in all. Open reduction internal fixation (ORIF) with a locking plate was performed for all thepatients along with intramedullary fibular autograft to support medial calcar. Radiological outcome was assessed by neck-shaft angle (NSA) graded according to the Paavolainen grading method and difference in thehumeral head height (HHH). Functional outcome was assessed by shoulder range of motion (ROM), University of California-Los Angeles (UCLA) score and American shoulder and elbow surgeons score (ASES). Radiological union at the fracture site was achieved in all the patients at mean of 8months (range 6-12months). Range of movements were mean flexion of 123.89, extension 35.28, internal rotation 66.94, external rotation 57.78 and abduction of 115° at final follow-up. The average NSA was in the range of 120°-130° and none of the patients showed difference in HHH of ≥ 4mm in the immediate post-operative radiograph and that taken on final follow-up. The functional outcome assessed by ASES score (mean 89.44) and UCLA score (mean 29.61) suggested fair to good results. None of the patients has shown varus collapse and avascular necrosis. Neither there were any complications related to the donor area. In unstable proximal humerus fractures with calcar comminution or void, PHILOS plate fixation augmented with fibular autograft as a medialsupport reduces varus collapse and promotes early radiological union.

Commentary on: Dual plate fixation for proximal humerus fractures with unstable medial column in patients with osteoporosis: A case-control study.

Commentary on: Dual plate fixation for proximal humerus fractures with unstable medial column in patients with osteoporosis: A case-control study.

Comparison of outcomes of internal fixation and non-operative management of 2-part and 3-part proximal humerus fractures in younger adults

Aims This study aimed to compare outcomes of internal fixation and non-operative management in younger adults. Methods A retrospective cohort study was undertaken in patients aged 18–55 with 2-part or 3-part proximal humerus fractures at a Level 1 trauma centre from January 2010 to December 2018. Outcome measures were the Oxford shoulder score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Statistical analysis included univariable analysis and multivariable analysis performed using binary logistic regression and linear regression. Results A total of 184 eligible patients were included; 99 underwent operative fixation and 85 were managed with sling immobilisation. The mean (SD) age in the operative group was 39.3 ± 10.6 and in the non-operative group was 43.2 ± 10.8 ( p = 0.02). Seventy-seven percent completed a minimum 12-month follow-up (median 3.2 years, IQR 2–6.5 years). Most 3-part fractures were treated surgically (78%), as opposed to 44% of 2-part fractures. All open fractures, all segmental fractures, eight head split fractures (89%), and 12 fracture-dislocations (80%) were treated surgically. There was no difference in mean OSS (43.7 operative vs 42.1 non-operative, p = 0.27), mean EQ-5D-5L utility score (0.81 vs 0.78, p = 0.32) or proportion returned to work (83% vs 75%, p = 0.34). Adjusted for case-mix, there was no difference in OSS (adjusted mean difference 0.24, 95%CI −2.73 to 3.22, p = 0.87) or EQ-5D-5L utility score (adjusted mean difference 0.00, 95%CI −0.06 to 0.07, p = 0.96). The complication rate was high (36% non-operative, 27% operative, p = 0.24). A higher rate of varus malunion was observed in the non-operative group (24.0% vs 41.4%, p &lt; 0.001). Following operative management, 23% underwent subsequent surgery compared with 7% of the non-operative group ( p = 0.002). Conclusion In younger adults with proximal humerus fractures no differences in patient reported outcome measures were observed between groups. Operative management was associated with improved radiological outcomes, but a higher rate of subsequent surgery.

Effects of anti-osteoporosis therapy on the risk of secondary fractures and surgical complications following surgical fixation of proximal humerus fracture in older people.

age-related fragility fractures cause significant burden of disease. Within an ageing society, fracture and complication prevention will be essential to balance health expenditure growth. to assess the effect of anti-osteoporotic therapy on surgical complications and secondary fractures after treatment of fragility fractures. retrospective health insurance data from January 2008 to December 2019 of patients ≥65years with proximal humeral fracture (PHF) treated using locked plate fixation (LPF) or reverse total shoulder arthroplasty were analysed. Cumulative incidences were calculated by Aalen-Johansen estimates. The influence of osteoporosis and pharmaceutical therapy on secondary fractures and surgical complications were analysed using multivariable Fine and Gray Cox regression models. a total of 43,310 patients (median age 79years, 84.4% female) with a median follow-up of 40.9months were included. Five years after PHF, 33.4% of the patients were newly diagnosed with osteoporosis and only 19.8% received anti-osteoporotic therapy. A total of 20.6% (20.1-21.1%) of the patients had at least one secondary fracture with a significant reduction of secondary fracture risk by anti-osteoporotic therapy (P < 0.001). An increased risk for surgical complications (hazard ratio: 1.35, 95% confidence interval: 1.25-1.47, P < 0.001) after LPF could be reversed by anti-osteoporotic therapy. While anti-osteoporotic therapy was more often used in female patients (35.3 vs 19.1%), male patients showed significantly stronger effects reducing the secondary fracture and surgical complication risk. a significant number of secondary fractures and surgical complications could be prevented by consequent osteoporosis diagnosis and treatment particularly in male patients. Health-politics and legislation must enforce guideline-based anti-osteoporotic therapy to mitigate burden of disease.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures. A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates. Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort. Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

The medial cortical ratio as a risk factor for failure after surgical fixation of proximal humerus fractures in elderly patients.

This study aims to investigate whether the medial cortical ratio (MCR) is associated with fixation failure in patients undergoing plate-screw fixation due to proximal humeral fracture. Between May 2011 and October 2020, a total of 93 patients (25 males, 68 females; mean age: 74.2±5.3 years; range, 65 to 92 years) who were operated for a proximal humeral fracture were retrospectively analyzed. The patients were divided into two groups during follow-up: patients with fixation failure (n=18) and patients with intact fixation (n=75). After radiological analysis, the MCR and fracture type were recorded. The effects of MCR and fracture type on the development of failure were evaluated. The mean follow-up was 41.3±4.7 (range, 18 to 66) months. There was no significant correlation between fixation failure and MCR in either group (p=0.535). However, the risk of fixation failure increased by seven-fold in patients with MCR greater than 0.09 compared to the other patients. In addition, the fracture type was significantly more severe in the failed fixation group than the intact fixation group (p<0.001). Surgical treatment of proximal humeral fractures in elderly patients still remains a challenge for surgeons due to the high failure rate. In elderly patients scheduled for surgery to treat a proximal humerus fracture, a reverse shoulder arthroplasty may be a reasonable choice to avoid reoperation due to fixation failure in elderly with three-part or more fragmented fractures and high MCR.

Influence of preoperative simulation on the reduction quality and clinical outcomes of open reduction and internal fixation for complex proximal humerus fractures

PurposeProximal humerus fractures (PHFs) are common. With the development of locking plates, open reduction and internal fixation (ORIF) of the proximal humerus can provide excellent clinical outcomes. The quality of fracture reduction is crucial in the locking plate fixation of proximal humeral fractures. The purpose of this study was to determine the impact of 3-dimensional (3D) printing technology and computer virtual technology assisted preoperative simulation on the reduction quality and clinical outcomes of 3-part and 4-part proximal humeral fractures.MethodA retrospective comparative analysis of 3-part and 4-part PHFs undergoing open reduction internal fixation was performed. Patients were divided into 2 groups according to whether computer virtual technology and 3D printed technology were used for preoperative simulation: the simulation group and the conventional group. Operative time, intraoperative bleeding, hospital stay, quality of fracture reduction, Constant scores, American Society for Shoulder and Elbow Surgery (ASES) scores, shoulder range of motion, complications, and revision surgeries were assessed.ResultsThis study included 67 patients (58.3%) in the conventional group and 48 patients (41.7%) in the simulation group. The patient demographics and fracture characteristics were comparable in these groups. Compared with the conventional group, the simulation group had shorter operation time and less intraoperative bleeding (P < 0.001, both). Immediate postoperative assessment of fracture reduction showed a higher incidence of greater tuberosity cranialization of < 5 mm, neck-shaft angle of 120° to 150°, and head shaft displacement of < 5 mm in the simulation group. The incidence of good reduction was 2.6 times higher in the simulation group than in the conventional group (95% CI, 1.2–5.8). At the final follow-up, the chance of forward flexion > 120° (OR 5.8, 95% CI 1.8–18.0) and mean constant score of > 65 (OR 3.4, 95% CI 1.5–7.4) was higher in the simulation group than the conventional group, as well as a lower incidence of complications in the simulation group was obtained (OR 0.2, 95% CI 0.1–0.6).ConclusionsThis study identified that preoperative simulation assisted by computer virtual technology and 3D printed technology can improve reduction quality and clinical outcomes in treatment of 3-part and 4-part PHFs.

Translated article] Comparative biomechanical study of two configurations of cemented screws in a simulated proximal humerus fracture fixed with locking plate

IntroductionScrew tip augmentation with bone cement for fixation of osteoporotic proximal humerus fractures seems to improve stability and to decrease the rate of complications related to implant failure. However, the optimal augmentation combinations are unknown. The aim of this study was to assess the relative stability of two augmentations combinations under axial compression load in a simulated proximal humerus fractures fixed with locking plate. Material and methodsA surgical neck osteotomy was created in five pairs of embalmed humeri with a mean age of 74 years (range 46–93 years), secured with a stainless-steel locking-compression plate. In each pair of humeri, on the right humerus were cemented the screws A and E, and in the contralateral side were cemented screws B and D of the locking plate. The specimens were first tested cyclically in axial compression for 6000 cycles to evaluate interfragmentary motion (dynamic study). At the end of the cycling test, the specimens were loaded in compression force simulating varus bending with increasing load magnitude until failure of the construct (static study). ResultsThere were no significant differences in interfragmentary motion between the two configurations of cemented screws in the dynamic study (p=0.463). When tested to failure, the configuration of cemented screws in lines B and D demonstrated higher compression load to failure (2218N vs. 2105, p=0.901) and higher stiffness (125N/mm vs. 106N/mm, p=0.672). However, no statistically significant differences were reported in any of these variables. ConclusionsIn simulated proximal humerus fractures, the configuration of the cemented screws does not influence the implant stability when a low-energy cyclical load is applied. Cementing the screws in rows B and D provides similar strength to the previously proposed cemented screws configuration and could avoid complications observed in clinical studies.

Dual plate fixation of proximal humerus fractures: Retrospective review and surgical technique.

Recent interest has been directed towards dual plate fixation for comminuted proximal humerus fractures, with an aim to improve construct stability and thus improve patient outcomes while decreasing the risk of fracture-associated complications. We present our experience with this technique in a case series of patients with proximal humerus fractures and describe our surgical technique. This was a single-center retrospective case series of patients presenting with an acute (<6 weeks) proximal humerus fracture who underwent ORIF with dual plating fixation. Patient, fracture, and surgical data were collected. All patient outcomes were evaluated using Constant-Murley shoulder score and Single Assessment Numeric Evaluation. Our series included nine patients with a mean age of 46.2 years (range: 27-70 years old). All fractures healed within 4 months and no complications were encountered. At 1 year follow-up, the mean SANE score was 69.4% and the mean Constant Murley shoulder score was 78.9 (range: 70-96). Our current series shows that applying the dual plating technique in severely comminuted proximal humerus fractures provides adequate fixation and thus good patient outcomes. Further research is required before this technique can be strongly recommended for management of these complex fractures. Level 5.