Necrosis Of Humeral Head Research Articles

High bone consolidation rates after humeral head-preserving revision surgery in non-unions of the proximal humerus

Fractures of the subcapital and proximal humerus shaft region are common fractures of the human skeleton. Their treatment should provide an early functional after-care of the shoulder joint, that is prone to arthrofibrosis. Although the upper extremity is not weight-bearing the occurrence of proximal humerus non-unions leads to severe impairment with inability to work and restrictions of activity of daily life. The aim of this study was to investigate whether an operative revision of proximal humerus non-unions with reosteosynthesis and application of distant autologous bone grafts can lead to sufficient bone healing. The second aim was to find out whether patients achieved an acceptable functional outcome, as alternatively patients could be treated by reconstruction with a shoulder prosthesis. 27 patients (female = 15, male = 12) with reosteosynthesis of the proximal humerus and proximal humeral shaft due to non-union after initially operative fracture treatment were included between 2008 and 2014. Average age of patients was 56 years (23-87), 48% had no comorbidities, while 52% of the patients had at least 1 comorbidity such as diabetes, hypertension or nicotine abusus. The mean number of prior surgical intervention was 1.2 (1-3). The mean time between initial surgery and re-osteosynthesis was 12.3 months. Patients with signs of infection pseudarthrosis were excluded. The initial type of osteosynthesis was with plates (n = 16; thereof PHILOS Plate n = 14), and intramedullary nails (T2, Targon Nail, PHN, Seidel Nail; n = 11). Revision surgery was done with plate osteosynthesis (n = 26; thereof PHILOS Plate n = 4; LC Plate n = 10; angle plate n = 12). In 23 patients (89%) a distant bone transplantation was done from the iliac crest, and 1 patient received allogenous bone. Three patients (11%) received bone morphogenetic protein 7 (BMP 7) in combination with distant bone graft. Intraoperative swabs from the pseudarthrosis area showed no bacterial pathogen after 14 days of incubation. DASH score and Constant score were used to evaluate the functional outcome after revision surgery. Bone healing was determined by standard X-rays and evaluated by a modified radiological score. 89% of the patients could be followed for an average of 28 months and the radiological follow-up was at 9 months. The radiological score showed very good (50%), or good results, and a sufficient bone healing was shown in 25 of 27 patients (93%). The pseudarthrosis revision surgery failed in two cases (n = 1 persisting non-union; n = 1 humeral head necrosis after re-operation with angle plate). DASH scores provided a mean of 40 ± 28.8 with a range from 0-97 points, and the results from the Constant score provided 45 ± 25.4. The analysis with variation of age showed a trend for better results in female patients < 60 years of age. As complications after bone graft 3 patients had persistent local dysesthesia (11%), in one case fracture of the iliac bone occurred that healed with conservative treatment. The pseudarthrosis revision surgery with humeral head preserving re-osteosynthesis with bone transplantation is an effective treatment for non-unions of the proximal humerus and the proximal humeral shaft and the current results showed high bone consolidation rates. As the functional results remained limited after revision an individual treatment decision should be made concerning the most appropriate therapy. While a shoulder prosthesis may be considered in the aged patient, a revision strategy with reosteosynthesis should be considered particularly in younger patients.

Double plating for obsolete proximal humeral fractures with instability of medial metaphysis

Objective To evaluate the results of double plating for obsolete proximal humeral fractures whose instability of medial metaphysis cannot be maintained conventionally.Methods From January 2005 to June 2012,we treated 10 patients with the obsolete proximal humeral fracture mentioned above with double plating.They were 6 men and 4 women,aged from 26 to 51 years (average,38.8 years).The fractures involved 8 principal sides (all right sides).By the Neer classification,7 cases were two-part varus fractures of surgical neck,one three-part fractures of greater tubercle,and 2 four-part fractures (non-abduction compact ones).The range of motion of the shoulder,visual analogue scale (VAS),American Shoulder and Elbow Score (ASES),Constant-Murley score,University of California-Los Angeles (UCLA) score and Simple Shoulder Test (SST) were all recorded for functional evaluation.The results were compared between preoperation and the last follow-up.Results The 10 patients were followed up for an average of 16.9 months (from 12 to 50 months).At the last follow-up,the forward flexion was 144.0° ± 30.6°,external rotation 34.5° ±27.2° and internal rotation up to T10 level on average.The Constant-Murley score was 84.4 ± 12.9,ASES 79.5 ± 20.2,UCLA 28.7 ± 5.1,SST 9.6 ± 1.7,and VAS 1.7 ± 2.5.By Constant evaluation,8 patients considered the results as excellent and the other 2 as good.There were significant differences between preoperation and the last follow-up regarding all the above indexes in the 10 obsolete fractures (P ＜ 0.05).Ischemic necrosis of the humeral head occurred in 2 cases and delayed union in one.No other complications were observed.Conclusion Double plating can lead to satisfactory outcomes in treatment of obsolete proximal humeral fractures whose instability of medial metaphysis cannot be maintained conventionally. Key words: Shoulder fractures; Fracture fixation, internal; Bone plates; Range of motion,articular

Efficacy of pressurized proximal humerus proximal humeral locking plate fractures

Objective To observe the clinical efficacy of relatively proximal humeral locking compression plate（ LPHP） with the traditional plate for treatment of proximal humeral fractures .Methods The proximal humeral fractures in patients with 58 cases,the patients were divided into two groups ,the treatment group of 32 cases of locking compression plate in the treatment of T plate ,clover plate in the treatment of 26 patients of the control group received traditional.According to the Neer score compared with two groups of patients with postoperative recovery and compli -cations.Results All the 58 patients for 11 ~15 months of follow-up,the treatment group found no fracture ,fracture nonunion,screw and plate humeral head necrosis ,4 cases of shoulder pain was limited;15 cases of excellent score Neer function,good in 12 cases,5 cases,the excellent and good rate was 84.4%.The control group had 3 cases,2 ca-ses of screw loosening of plate fracture ,3 cases of nonunion ,2 cases of humeral head necrosis ,7 cases of shoulder pain limited.6 cases of excellent score Neer function ,good in 9 cases,3 cases,poor in 8 cases,the excellent and good rate was 57.7%.There was significant differences between the two groups （χ2 =5.113,P <0.05） excellent rate. Conclusion LPHP exact treatment of proximal humeral fractures has fewer complications , which can help patients with early rehabilitation exercises . Key words: Bone wires; Fracture fixation,internal; Humerus fractures

Osteoporotic fracture of proximal humerus treated with Spatial Subchondral Support(S3) locking plate of proximal humerus

Objective To evaluate the surgical techniques and clinical outcomes of treating osteoporotic fracture of proximal humerus with Spatial Subchondral Support (S3) locking plate of proximal humerus.Methods From July 2010 to July 2011,21 patients with osteoporotic fracture of proximal humerus,12 males and 9 females,were treated in our department.They were 66.0 years old on average (from 58 to 80 years old).According to the Neer classification system,13 cases were 3-part fractures,8 4-part fractures,and 2 combined with shoulder dislocation.All cases were evaluated carefully with routine CT scans pre-operatively to define the type of fracture and the involvement of articular surface.Open reduction and internal fixation with S3 locking plate of proximal humerus was performed 2 to 7 days after injury (average,4.0 days).Regular X-ray follow-ups were taken and complications recorded as well.Overall function evaluation was carried out according to the modified Constant-Murley score system (CMS) and visual analogue scale (VAS).Results The 18 cases were followed up for a mean duration of 18.0 months (from 12 to 24 months).No complications of wound infection,implant failure or impingement were observed during the follow-ups.Bone union was achieved after an average of 12.0 weeks (from 10 to 14 weeks).On average,the Modified CMS score was 80.2 and the VAS score 1.5.At the post-operative 10th and 13th months,X-ray manifested avascular necrosis of the humeral head respectively in 2 cases of 4-part fractures,who suffered from moderate pain which was relieved after conservative treatment.Conclusion Fixation with S3 locking plate of proximal humerus is a safe and effective treatment of osteoporotic fracture of proximal humerus,because it is rigid and avoids plate-related impingement. Key words: Humerus; Shoulder fractures; Fracture fixation, internal; Bone plates

Percutaneous Plating of the Proximal Humerus

Percutaneous plating was developed in an attempt to address the issues of humeral head necrosis associated with open reduction through an extensive approach and insufficient primary stability associated with previous attempts at limited exposure with minimal internal fixation. Our minimally invasive approach consists of 2 separate mini-incisions. The proximal incision is a direct anterolateral deltoid-splitting approach of <5 cm that exposes the humeral head and tuberosities. The distal incision of 1 to 2 cm exposes the humeral shaft and distal part of the plate. Before plate insertion underneath the deltoid, the axillary nerve must absolutely be identified and protected to prevent entrapment. The block guide attachment to the plate cannot be safely used as it stretches directly the nerve at the distal edge. With our approach, indirect reduction techniques are needed to achieve good reduction. Ideal fracture types include 2-part surgical neck fractures, isolated greater tuberosity fractures, and all valgus-type injuries. With increased experience, indications can be extended to many 3-part fractures and some 4 parts. Good outcomes can be expected if patients are well selected.

Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970–2009

BackgroundThe optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns.MethodsThe databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test.ResultsHemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)].The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores.DiscussionDespite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.

Indikation zur primären Frakturendoprothetik der Schulter

Although fractures of the proximal humerus are one of the most common osteoporotic fracture types, no generally accepted treatment algorithm exists in the current literature. For young patients with high functional demands and good rehabilitation potential, we recommend humeral head salvage therapy. If symptomatic humeral head necrosis occurs, the implantation of an anatomic endoprothesis is possible on a secondary basis. For patients with a biological age > 70 years suffering from a persisting defect of the rotator cuff along with a humeral head fracture or from a multiple fragment fracture of the humeral head, we increasingly prefer implantation of a reverse shoulder prosthesis due to good clinical results. However, because of technical aspects and a high complication rate, treatment using the reverse fracture prosthesis should be reserved for surgeons with expertise in this particular field. After analyzing the fracture- and patient-specific risk factors and performance expectations, the trauma surgeon can select the best individual therapy with the patient.

Nailing of three- and four-part fractures of the humeral head – Long-term results

Background and purposeLong term outcome of the treatment of displaced complex fractures of humeral head is rare in the literature especially in greater cohorts. Main purpose of our study was the assessment of long term results of intramedullary nailing of 3–4 part fractures. Patients and methods137 patients with 137 three or four-part fractures of the humeral head treated by intramedullary nailing were reassessed after an average follow-up time of 57 (27–93) months. The whole cohort consisted of 85 three-part fractures, 38 four-part fractures and 14 fracture-dislocations. Radiographic and clinical outcome – absolute Constant score (CSabs) and relative Constant score (compared to the contralateral side – CSrel) were evaluated. The rate of complications was recorded. Analysis of the influence of quality of achieved reduction on final functional result and on the development of complications was performed. Results125 fractures healed uneventfully. Mean long term CSrel was 81% of the unaffected side. Mean CSrel was 85% in 3-part fractures, 73% in four-part fractures, 80% in three-part fracture-dislocations and 70% in four-part fracture-dislocations. 96 (70%) patients achieved excellent or good results (CSrel higher than 80%), 17 (12.4%) satisfactory results and 24 (17.5%) poor results (CSrel less than 60%). No significant difference was observed in functional results between different age groups. No incidence of non-union was observed, 4 losses of reduction were encountered. We observed 17 cases of complete humeral head necrosis, 14 of them in the group of 4-part fractures. Reduction quality strongly influenced functional result and development of head necrosis. In the group of excellent reduction mean CSrel was 88% and the rate of necrosis was 2%. Moderate reduction quality deteriorated CSrel to 70% and head necrosis rate rose up to 28%. If reduction was poor, mean CSrel was 52% and the rate of complete necrosis rose to 60%. ConclusionLong term results confirmed nailing as appropriate treatment strategy for all types of humeral head fractures with limitation of excellent reduction in every age group. Moderate or even poor reduction significantly deteriorates functional results and increases rate of complete necrosis of the humeral head. If good reduction cannot be achieved, treatment strategy should be changed.

Salvage of shoulder joint through simplification of wound management

Infection is a common sequela of open dislocation of the shoulder joint. This typically leads to joint surface and humeral head necrosis, resulting in severe limitation of motion. Few cases of open and infected glenohumeral joints have been reported, and none had a good functional outcome with pain-free, near-full range of motion. Here we report the case of a 24-year-old man, who sustained a severe degloving injury of his left shoulder with an open glenohumeral joint, in a road traffic accident. We describe a treatment plan that salvaged near-full range of shoulder motion and resulted in pain-free active and passive movements.

Minimally Invasive Fixation for Proximal Humeral Fracture: A Review on the use of T2 Proximal Humeral Nail: 以T2近端肱骨髓內釘為近端肱骨骨折病人進行微創內固定手術的回顧性研究

Objective and methodologyA retrospective review of the outcome of patients who had proximal humeral fracture treated with T2 Proximal Humeral Nail from January 2007 to March 2011 was conducted. The demographics, union rate, and complications were reviewed. The patient outcome was assessed with the American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score. ResultsThirty-two cases of traumatic proximal humeral fractures were included. The average follow-up period was 14.7 months. All fractures healed with an average of 3.97 months. The average forward flexion and lateral abduction of shoulder was 132° and 123°, respectively. The postoperative average Constant-Murley score was 67 (48-80) and ASES score was 82.9 (73-100). There was one case of avascular necrosis of humeral head. Six cases of minor screw complications required removal of screws later. No wound infection or neurovascular injury was found. Discussion and conclusionWith the proper surgical technique high union rate, good functional recovery, and low complication rate can be achieved by using T2 Proximal Humeral Nail in managing traumatic proximal humeral fracture.

Simultaneous posterior fracture dislocation of the shoulder following epileptic convulsion.

Shoulder dislocations with fractures are a possible complication of an epileptic seizure and are often missed on the first sight. The incidence of sustaining an avascular humeral head necrosis (AVN) is high, and primary prosthetic replacement is the choice of treatment. In this paper, we describe such a rare case: a 48-year-old male patient sustained simultaneous bilateral posterior shoulder dislocation with fractures of both humeral heads following the first episode of an epileptic convulsion. On the left side, open reduction and internal fixation were performed with angle stable plate osteosynthesis. In the same operation, a hemi-prosthesis was implanted on the right side. One and a half years postoperatively, function on the right side is unsatisfying and AVN is seen on the left side and secondary prosthetic replacement had to be performed. In case of a shoulder dislocation with a complex fracture after an epileptic seizure, prosthetic replacement is the choice of treatment.

Novel Treatment for Osteonecrosis of the Humeral Head Using the Trufit Plug: A Synthetic Bone-Graft Substitute

Treatment of avascular necrosis of the humeral head is a challenging clinical problem because patients often present at a young age with established destruction of bony tissue. Reccommended surgical treatment at this stage of the disease is joint replacement surgery using a metal implant, although this has potential complications. The present case report describes the novel use of a synthetic bone-graft substitute (TruFit plug; Smith &amp; Nephew, Andover, MA, USA) that was successfully used to restore full range of movement and completely alleviate pain in a patient with stage II avascular necrosis of the right humeral head.

Treatment of comminuted fractures of the proximal humerus with locking proximal humeral plate

Objective To evaluate the efficacy of locking proximal humeral plate (LPHP) for the treatment of comminuted fractures of proximal humerus in comparison with anatomical proximal humeral plate (APHP) and T-shaped plate.Methods From August 2008 to September 2010,65 patients with comminuted fracture of proximal humerus of Neer types Ⅱ-Ⅳ were treated in our department.They were 36 men and 29 women,with an average age of 39 years (from 24 to 70 years).LPHP was used in 36 patients (group A),APHP in 19 patients (group B) and T plate in 10 patients (group C).All the operations were conducted through the deltoid-pectoral-gap,and autografts were transplanted in the cases of bone defects after reduction.Exercises were done 1 to 6 weeks postoperation to prevent shoulder anchylosis.The clinical outcomes were compared between the 3 methods,including fracture healing,Neer score and complications.Results All the patients were followed up from 12 to 18 months (14.5 months on average).Fracture union was achieved in 36 cases in group A,in 17 cases in group B and in 8 cases in group C,with significant between-group differences ( P ＜ O.05).The mean healing time was 10.1 ± 1.2 weeks in group A,12.3 ± 1.4 weeks in group B and 15.4 ±2.6 weeks in group C,with significant between-group differences ( P ＜ 0.05).Humeral head necrosis occurred in 2 cases in group B and in 2 cases in group C,with a significant difference between group A and groups B and C ( P ＜ 0.05).By Neer scoring system,the good to excellent rate of shoulder function was 97.2％ in group A,63.2％ in group B and 40.0％ in group C,with significant between-group differences ( P ＜ O.05).Conclusion LPHP can be considered as the standard-therapy for comminuted fractures of proximal humerus of Neer types Ⅲ - ⅣV,because it can firmly fixate the comminuted fractures of the proximal humerus,leading to fast fracture healing,good functional recovery and limited complications. Key words: Shoulder fractures; Fractures, comminuted; Fracture fixation, internal; Bone plates

Management of proximal humeral Neer 3-part and 4-part fracture dislocations with anatomic reconstruction locking plate

Objective To analyze the therapeutic effect of open reduction with internal fixation (ORIF) and anatomic reconstruction locking plate in treatment of Neer 3-part and 4-part fracture dislocations of proximal humerus. Methods The study involved 30 patients with Neer 3-part and 4-part fracture dislocations treated with anatomic reconstruction locking plate from September 2004 to December 2007.Twenty patients had complete follow-up data.The treatment methods included locking proximal humeral plate (LPHP) in seven patients and proximal humeral internal locking system (PHILOS) in 13.There were 15 males and five females,at age range of 29-84 years (average 52.5 years),including nine patients younger than 65 years and 11 older than 65 years.According to Neer classification,there were 15 patients with 3-part fracture dislocations including 12 anterior and three posterior dislocations and five patients with 4-part fracture dislocations including four anterior and one posterior dislocations. VAS and Constant scoring system were adopted to evaluate the shoulder joint function postoperatively. Results All 20 patients were followed up for 36-71 months ( average 51 months),which showed avascular necrosis of humeral head in six patients (30％),plating loosening in two,screw penetration in six,nonunion in two and infection in two.The mean visual analogue score (VAS) was 2.55 poiuts and the mean Constant score for the shoulder was 80.8.According to the Neer shoulder functional evaluation standard,eight patients were graded as excellent,six as good,three as fair and three as poor,with excellence rate of 70％.Conclusions Although the anatomic reconstruction locking plate and ORIF can cause a high incidence of avascular necrosis of humeral head in the treatment of Neer 3-part and 4-part fracture dislocations of proximal humerus,especially for the patients older than 65 years.However,there is no obvious correlation between necrosis of humeral head and shoulder function.Clinically,the method could be selected on the ba-sis of individual condition of the patients. Key words: Shoulder fractures; Fracture fixation, internal; Shoulder dislocation

Vergleich Philos- vs. Königseeplattenosteosynthese bei der operativen Versorgung von 4-Fragment-Frakturen des proximalen Humerus bei über 65-jährigen Patienten

Although being one of the most common fractures in elderly patients, there is still no standardised treatment protocol for four-part fractures of the proximal humerus. However, a wide variety of angular-stable implants is available. The present retrospective study compares the clinical and radiological outcome following operative treatment of four-part fractures of the proximal humerus with the Philos system (Philos, proximal humeral internal locking system, Synthes GmbH, Umkirch Germany) and the angular-stable Königsee plate system (Königsee Implantate GmbH, Allendorf, Germany) in patients older than 65 years. From July 2005 until December 2007 we identified 77 patients with a four-part fracture of the proximal humerus who were treated operatively with one of the two implant systems. Of the patients, 17 could not be located so that in total 60 patients (78 %) participated in this study. The mean age of the 30 patients (10 m, 20 f) in the Philos group was 69 years (65-92), whereas the mean age of the 30 patients (11 m, 19 f) in the Königsee group was 71 years (65-93). A comprehensive assessment was performed after a median of 17 months (12-24), including physical examination, radiographic examination and completion of the disabilities of the arm, shoulder and hand score (DASH) and the Constant score (CS) as patient-oriented, limb-specific questionnaires. Neither in the Philos nor in the Königsee group could excellent results be achieved. Using the CS 13 patients (43 %) of the Philos group achieved a good and 15 (50 %) a satisfactory result. Bad results were found in 2 patients (7 %). The mean CS was 61.53 points. In the Königsee group mean CS was 61.76 points. In detail, 14 patients (47 %) treated with the Königsee implant were rated as good and 15 (50 %) as satisfactory. Only 1patient (3 %) was rated as poor. No significant statistical differences were found between the groups. Mean DASH score in the Philos group was 56.30 points and 55.37 points in the Königsee group. Again, no statistical difference was found. Partial humeral head necrosis was observed in 2 patients of the Philos and 1 of the Königsee group. In the remaining patients uneventful fracture consolidation was observed. There were no complications requiring further surgical intervention. To the date of follow-up all implants were still in situ and none of the patients reported discomfort with respect to the hardware. In this study we were able to demonstrate that good and satisfactory results can be achieved in the majority of patients, regardless of whether a Philos or a Königsee system was used. Significant differences between the two groups could not be found in any of the performed examinations. Both implants seem to be suitable in four-part fractures of the proximal humerus. However, the Königsee plate represents a more cost-effective option compared to the Philos system.

Osteonecrosis of the Humeral Head in a Patient with Non-small Cell Lung Cancer Receiving Bevacizumab

A 43-year-old Filipino woman, never-smoker, was diagnosed with stage IV adenocarcinoma of the lung in February 2009, with metastatic disease to the liver and brain. The biopsies of the lung mass and liver confirmed poorly differentiated, TTF-1-positive, EGFR-mutated (exon 19) adenocarcinoma of the lung. The patient underwent a craniotomy followed by brachytherapy for the isolated brain metastases. Subsequently, she initiated erlotinib plus celecoxib versus placebo on a clinical trial in April 2009, to which she responded for 12 months. In February 2010, she initiated second-line carboplatin/pemetrexed/bevacizumab for six cycles with complete resolution of the positron emission tomography uptake to the lung primary and liver metastases. The patient started maintenance bevacizumab in June 2010. In February 2011, she presented with left shoulder pain with absence of trauma or bone metastases. Magnetic resonance imaging of the shoulder revealed avascular necrosis of the left humeral head (Figure 1). The positron emission tomography/ computed tomography scan showed mild fluorodeoxyglucose uptake to the left shoulder and a stable, fluorodeoxyglucosenegative, left upper lobe mass (Figure 2). After the diagnosis of avascular necrosis was made, bevacizumab was discontinued and the patient initiated maintenance pemetrexed. Her pain responded to anti-inflammatory medications. Avascular necrosis of the femoral head has been reported in two patients with colorectal cancer receiving bevacizumab and one patient receiving sunitinib.1 Prolonged antiangiogenic therapy may impair the bone metabolism leading to osteonecrosis.2 To our knowledge, this is a first report of osteonecrosis of the humeral head in a patient treated with bevacizumab alone without bisphosphonates or other agents with increased risk of bone necrosis.

The calcar screw in angular stable plate fixation of proximal humeral fractures - a case study

BackgroundWith new minimally-invasive approaches for angular stable plate fixation of proximal humeral fractures, the need for the placement of oblique inferomedial screws ('calcar screw') has increasingly been discussed. The purpose of this study was to investigate the influence of calcar screws on secondary loss of reduction and on the occurrence of complications.MethodsPatients with a proximal humeral fracture who underwent angular stable plate fixation between 01/2007 and 07/2009 were included. On AP views of the shoulder, the difference in height between humeral head and the proximal end of the plate were determined postoperatively and at follow-up. Additionally, the occurrence of complications was documented. Patients with calcar screws were assigned to group C+, patients without to group C-.ResultsFollow-up was possible in 60 patients (C+ 6.7 ± 5.6 M/C- 5.0 ± 2.8 M). Humeral head necrosis occurred in 6 (C+, 15.4%) and 3 (C-, 14.3%) cases. Cut-out of the proximal screws was observed in 3 (C+, 7.7%) and 1 (C-, 4.8%) cases. In each group, 1 patient showed delayed union. Implant failure or lesions of the axillary nerve were not observed. In 44 patients, true AP and Neer views were available to measure the head-plate distance. There was a significant loss of reduction in group C- (2.56 ± 2.65 mm) compared to C+ (0.77 ± 1.44 mm; p = 0.01).ConclusionsThe placement of calcar screws in the angular stable plate fixation of proximal humeral fractures is associated with less secondary loss of reduction by providing inferomedial support. An increased risk for complications could not be shown.

소아에서 동측 상완골 외과적 경부 골절을 동반한 외상성 견관절 후방 탈구 - 증례 보고 -

Purpose: Traumatic posterior dislocation of the shoulder in a child is extremely rare, and posterior dislocation of the shoulder concomitant with ipsilateral humeral surgical neck fracture has not been reported in a child previously in Korea. Materials and Methods: The authors treated a 10-year-old with posterior dislocation of left shoulder and an ipsilateral humeral surgical neck fracture, that occurred during Taekwondo practice, by open reduction of the shoulder and pin fixation under general anesthesia. Results: A normal range of motion with complete union and good remodeling was achieved without redislocation or avascular necrosis of humeral head at 1 year after surgery. Conclusion: The authors report a successfully treated case of traumatic posterior dislocation of the shoulder with an ipsilateral humeral surgical neck fracture in child.

Surgical treatment of two-part fractures of the proximal humerus: Comparison of fixed-angle plate osteosynthesis and Zifko nails

Introduction Closed reduction and percutaneous pinning using Zifko nails offer the advantage of a minimal soft-tissue dissection but have been criticised for limited stability and secondary fracture dislocation. Angular stable plate osteosynthesis enables anatomic reduction, but carries the risk of soft-tissue traumatisation and consecutive humeral head necrosis. The present study compares the clinical and radiological outcome of patients with dislocated two-part fractures of the proximal humerus, who were treated with either Zifko nails or angular stable plate fixation. Material and methods A matched-pair analysis was performed and patient groups were matched according to age (±3 years), sex and fracture type. As many as 11 pairs of patients with a minimum follow-up of 3 years were formed and investigated radiographically and clinically using the Constant score (CS) and the visual analogue scale (VAS) for the patients’ satisfaction. Results At the time of follow-up, the absolute CS was 83 points in the PHP group and 78 points in the Zifko group (n.s.). Neither in the age and gender-corrected CS was found a significant difference between the study groups (PHP 104 ± 29, Zifko 95 ± 17, n.s.) nor in terms of subjective patient satisfaction (PHP 6.54; Zifko 7.8, n.s.). The complication rate was also comparable in both groups. Conclusion In conclusion, Zifko nailing represents a cost-effective minimally invasive surgical method with a complication rate and clinical outcome comparable to that after angular stable osteosynthesis by angular stable plate fixation in the treatment of two-part fractures of the proximal humerus.

Early results for treatment of valgus impacted four-part proximal humerus fractures using the PHILOS plate system

Objective To evaluate the clinical results of open reduction and internal fixation of valgus impacted four-part proximal humerus fractures with the AO proximal humeral internal locking system (PHILOS). Methods Eleven patients (mean age 42 years) with four-part valgus impacted fracture of the proximal humerus underwent operations. The exposure was limited tothe lateral side of the intertubercular sulcus and the periosteal continuity of the lesser tubercle was preserved. When the humeral head was reduced, autograft or allograft bone was implanted to the site of bone defects, and subsequently the PHILOS plate was used to fix the fractured bone. Results All cases were followed up 20 months after the surgery. Avascular necrosis of the humeral head was found in one case. The necrosis ratio was 9.1%. The mean angle of anterior flexion of the shoulder was 150°. The mean angles of external and internal rotation of the shoulder were 20° and Thl2, respectively. The mean JOA score was 91. Conclusion Open reduction and internal fixation with PHILOS locking plate can gain satisfactory therapeutic effects in the treatment of valgus impacted four-part proximal humerus fractures. Key words: Humerus; Fractures, bone; Treatment outcome; PHILOS plate