4-part Proximal Humerus Fractures Research Articles

Biomechanical Contribution of Tension-Reducing Rotator Cuff Sutures in 3-Part Proximal Humerus Fractures.

Using a cadaveric 3-part fracture model and cyclic loading protocol, our study objectives were to quantify the stabilizing effect of tension-reducing rotator cuff sutures in terms of fracture displacement across the surgical neck and greater tuberosity compared with a control group in which no sutures were used. Six matched pairs of fresh frozen specimens underwent a standardized, 3-part, proximal humerus fracture and were split into 2 groups. The control group had the fracture fixed with a plate and screw construct only while the experimental group had additional suture fixation through the plate to each rotator cuff tendon. Active abduction through the rotator cuff was simulated for 100, 200, 300, and 400 cycles and to failure at 1000 N. A Mann-Whitney U test compared cyclic displacement of the greater tuberosity and surgical neck fracture gaps and load to failure between the 2 groups. There was no significant difference (P > 0.05) in fracture gap between fixation methods at the surgical neck at 100 (P = 0.13), 200 (P = 0.07), 300 (P = 0.49), and 400 (P = 0.07) cycles. There was no significant difference (P > 0.05) between fixation methods in the fracture gap at the greater tuberosity at 100 (P = 0.39), 200 (P = 1.00), 300 (P = 0.31), and 400 (P = 0.59) cycles. There was no significant difference (P > 0.5) at 1000 N at the surgical neck (P = 0.70) or the greater tuberosity (P = 0.39). Tension-relieving rotator cuff sutures do not add stability to the repair of 3-part proximal humerus fractures. Varus collapse and greater tuberosity displacement are common complications associated with 3-part fractures. No mechanical data exist to demonstrate benefit of adding suture to a plate and screw construct for limiting fracture displacement.

Implicit modeling of screw threads for efficient finite element analysis of complex bone-implant systems

Finite element analysis is commonly used to assist in the development and evaluation of orthopedic devices. The physics of these models are simplified through approximations that enable more efficient simulations, without compromising the accuracy of the relative comparisons between implant designs or configurations.This study developed and evaluated a technique to approximate the behavior of a finely threaded screw using a smooth cylinder with the threads implicitly represented through interfacial contact conditions. This pseudo-threaded model was calibrated by comparing to simulations that explicitly modeled the thread geometry with frictional contact. A parametric analysis was performed with a single screw-in-bone system, five loading directions, and three Young׳s moduli that span the range of cancellous bone (200, 600, and 1,000MPa). Considering that screw cut-out from cancellous bone is a critical clinical issue in the osteoporotic proximal humerus, the pseudo-threaded model was compared with a bonded interface to examine three different screw configurations in a 3-part proximal humerus fracture across 10 patients.In the single screw-in-bone system, the pseudo-threaded model predicted the screw displacement of the explicitly threaded model with 1–5% difference and estimated the strain distributions and magnitudes more accurately than a bonded interface. Yet, the relative comparisons of implant stability across the three different screw configurations in the proximal humerus were not affected by the modeling choice for the bone–screw interface. Therefore, the bonded interface could serve as a more efficient methodology for making relative comparisons between implants that utilize the same thread profile.

Cementless anatomical prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: cadaver study and prospective clinical study with minimum 2 years followup.

Introduction: The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem for 3- and 4-part proximal humeral fractures. Materials and methods: This study consisted of two parts: a cadaver study with 22 shoulders and a multicenter prospective clinical study of 23 fracture patients evaluated at least 2 years after treatment. In the cadaver study, the locked stem (HumelockTM, FX Solutions) and its instrumentation were evaluated. In the clinical study, five senior surgeons at four different hospitals performed the surgical procedures. An independent surgeon evaluated the patients using clinical (Constant score, QuickDASH) and radiological (X-rays, CT scans) outcome measures. Results: The cadaver study allowed us to validate the height landmarks relative to the pectoralis major tendon. In the clinical study, at the review, abduction was 95° (60–160), forward flexion was 108° (70–160), external rotation (elbow at body) was 34° (0–55), the QuickDASH was 31 (4.5–59), the overall Constant score was 54 (27–75), and the weighted Constant score was 76 (31.5–109). Discussion: This preliminary study of hemiarthroplasty (HA) with a locked stem found results that were at least equivalent to published series. As all patients had at least a 2-year follow-up, integration of the locked stem did not cause any specific complications. These results suggest that it is possible to avoid using cement when hemiarthroplasty is performed for the humeral stem. This implant makes height adjustment and transosseous suturing of the tuberosities more reproducible.

Outcomes of Arthroscopic Hardware Removal Following Locked Plating of Proximal Humerus Fractures: A Prospective Study

the Visual Analog Scale (VAS), DASH questionnaire, American Shoulder and Elbow Surgeons Shoulder score (ASES), as well as the Constant score as outcome measures. Patients were examined by a non-treating physician to determine shoulder motion and strength of both the injured and contralateral upper extremity. A radiograph of the operated shoulder was obtained at the time of final follow up to measure the head-neck angle as well as to determine the presence or absence of post traumatic arthritis and avascular necrosis (AVN) in the humeral head. Results: The mean age of our patients at the time of surgery was 66.8 years (40.5 to 85.4). There were no intra-operative complications. Mean estimated blood loss (EBL) was 109 ml (10 to 300) and the mean operative time was 119 min (70 to 236). All patients were able to return to their pre-injury level of activity and all were satisfied with their result. The mean follow-up time was 5.9 years (1 to 13.5). The mean external rotation of the injured versus uninjured shoulder was 49 deg (25 to 85) vs. 59 deg (20 to 90) p1⁄40.003, internal rotation was to T10 (L5 to T6) vs. T9 (L1 to T4) p1⁄40.65, forward flexion was 143 deg (90 to 180) vs. 158 deg (110 to 180) p1⁄40.019, and abduction was 113 deg (60 to 180) vs. 120 deg (85 to 180) p1⁄40.07. The mean ASES score was 88.2 (33 to 100), DASH score 13.9 (0 to 73.3), and Constant score 68.9 (37.9 to 86.3). The mean head-neck angle was 129 deg (106-140). Post-operative complications included one case of subacromial impingement, 2 cases of avascular necrosis, one of which involved less than twenty-five percent of the articular segment with no collapse, and one with articular collapse that required revision to hemiarthroplasty. There was one case of capsular contracture requiring manipulation under anesthesia and arthroscopic capsular release 38 months after the index procedure. There were two cases of heterotopic ossification of which one required excision 5 months after the index procedure. There was one pin tract infection that resolved with oral antibiotics. Conclusion: The use of coral as a strut allograft is a simple, safe, and effective technique for the surgical treatment of 3 and 4-part valgus-impacted proximal humerus fractures leading to consistently high patient satisfaction.

PHILOS plate in Proximal Humerus Fracture – its functional outcome and complications

Background: Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of locking plates. The objective of this prospective study was to evaluate functional outcome and complications of proximal humeral fractures managed with proximal humerus internal locking system (PHILOS). Methods: 16 men and 9 women aged 19 to 82 (mean, 49.24) with an acute proximal humerus fracture were treated with PHILOS plate by using deltopectoral approach. Outcome measurements included Constant score, and complications, and radiographic assessment. Results: 11 patients had 2-part fractures, 11 patients had 3-part fractures, and 3 patients had 4-part fractures. After 6 month follow up, a mean constant score 57.4 was achieved. Outcomes were excellent in 16%, good in 44%, fair in 16% while poor in 24%. The Constant score was poorer for Neer type IV fractures as compared to other types. The most frequently occurring complications in our patient were malreduction 20%, screw perforation 16%, infections 12%, avascular necrosis 8%, frozen shoulder 8%, impingement 4% and plate pull out 4%. Conclusion: Fixation of proximal humerus fractures with proximal humerus locking plates is associated with satisfactory functional outcomes in 2-part and 3-part fracture. The incidence of complications and subsequent re-operation is relatively high. Advanced surgical skills and surgeon’s experience are considered to be more critical for successful operative treatment. Keywords: Proximal humerus fracture, PHILOS, constant score, deltopectoral, Neer type, locking plate

Treatment of proximal humerus fractures with a CFR-PEEK plate: 2-year results of a prospective study and comparison to fixation with a conventional locking plate

A radiolucent carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plate was recently introduced for fixation of proximal humerus fractures. Prospective clinical and radiographic results of patients treated with a CFR-PEEK plate are compared with those of patients treated with a conventional locking plate. Twenty-nine patients (mean age, 66 years) were treated with a CFR-PEEK plate for a 3- or 4-part proximal humerus fracture. Patients were clinically and radiographically re-examined at 6 weeks, 6 months, 12 months, and 24 months with the Simple Shoulder Test, Constant-Murley score (CMS), and Oxford Shoulder Score (OSS) as well as with simple radiographs. In addition, results were compared with a matched group of patients treated with a conventional locking plate. At the final follow-up examination at 24 months, patients achieved a mean Simple Shoulder Test score of 58%, a mean CMS of 71.3 points (range, 44-97), and a mean OSS of 27.4 points (range, 8-45). Bone union was confirmed in all patients. Compared with patients treated with the conventional locking plate, patients treated with the CFR-PEEK plate achieved significantly better results with regard to the CMS and the OSS (P = .038 and .029, respectively). Furthermore, loss of reduction with subsequent varus deformity was less frequently observed in the CFR-PEEK plate group. Fixation of proximal humerus fractures with a CFR-PEEK plate provides satisfying clinical and radiographic results after 2 years of follow-up. The results are comparable to those achieved with conventional locking plates.

Treatment of proximal humerus fractures in the elderly

Background and purpose — There is no consensus on the treatment of proximal humerus fractures in the elderly. Patients and methods — We conducted a systematic search of the medical literature for randomized controlled trials and controlled clinical trials from 1946 to Apr 30, 2014. Predefined PICOS criteria were used to search relevant publications. We included randomized controlled trials involving 2- to 4-part proximal humerus fractures in patients over 60 years of age that compared operative treatment to any operative or nonoperative treatment, with a minimum of 20 patients in each group and a minimum follow-up of 1 year. Outcomes had to be assessed with functional or disability measures, or a quality-of-life score. Results — After 2 independent researchers had read 777 abstracts, 9 publications with 409 patients were accepted for the final analysis. No statistically significant differences were found between nonoperative treatment and operative treatment with a locking plate for any disability, for quality-of-life score, or for pain, in patients with 3- or 4-part fractures. In 4-part fractures, 2 trials found similar shoulder function between hemiarthroplasty and nonoperative treatment. 1 trial found slightly better health-related quality of life (higher EQ-5D scores) at 2-year follow-up after hemiarthroplasty. Complications were common in the operative treatment groups (10–29%). Interpretation — Nonoperative treatment over locking plate systems and tension banding is weakly supported. 2 trials provided weak to moderate evidence that for 4-part fractures, shoulder function is not better with hemiarthroplasty than with nonoperative treatment. 1 of the trials provided limited evidence that health-related quality of life may be better at 2-year follow-up after hemiarthroplasty. There is a high risk of complications after operative treatment.

Philos Plate in Proximal Humerus Fracture–Its Functional Outcome and Complications

Background: Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of locking plates. The objective of this prospective study was to evaluate functional outcome and complications of proximal humeral fractures managed with proximal humerus internal locking system (PHILOS). Methods: 16 men and 9 women aged 19 to 82 (mean, 49.24) with an acute proximal humerus fracture were treated with PHILOS plate by using deltopectoral approach. Outcome measurements included Constant score, and complications, and radiographic assessment. Results: 11 patients had 2-part fractures, 11 patients had 3-part fractures, and 3 patients had 4-part fractures. After 6 month follow up, a mean constant score 57.4 was achieved. Outcomes were excellent in 16%, good in 44%, fair in 16% while poor in 24%. The Constant score was poorer for Neer type IV fractures as compared to other types. The most frequently occurring complications in our patient were malreduction 20%, screw perforation 16%, infections 12%, avascular necrosis 8%, frozen shoulder 8%, impingement 4% and plate pull out 4%. Conclusion: Fixation of proximal humerus fractures with proximal humerus locking plates is associated with satisfactory functional outcomes in 2-part and 3-part fracture. The incidence of complications and subsequent re-operation is relatively high. Advanced surgical skills and surgeon’s experience are considered to be more critical for successful operative treatment. Keywords: Proximal humerus fracture, PHILOS, constant score, deltopectoral, Neer type, locking plate

Locking plate fixation versus antegrade nailing of 3- and 4-part proximal humerus fractures in patients without osteoporosis. Comparative retrospective study of 63 cases

IntroductionThere is no consensus on the treatment of proximal humeral fractures. The goal of the present retrospective observational study was to compare functional and radiological results and complications of internal fixation using locking plates versus antegrade nailing in the treatment of non-osteoporotic Neer classification 3- and 4-part fractures after a least 1year of follow-up. Material and methodsInternal fixation was performed in 67 fractures (1 bilateral): 35 by locking plate (1 lost to follow-up, 1 deceased) and 32 by intramedullary nailing (2 lost to follow-up) between January 1st, 2004 and December 31st, 2010. Thus, the study included 33 plates (21 3-part and 12 4-part fractures) and 30 nails (21 3-part and nine 4-part fractures). Final functional assessment was based on the Oxford, Constant, Relative Constant and QuickDASH scores and percentage of handicap. Radiological follow-up included immediate postoperative, 6weeks, 3months and 1year AP and Lamy lateral views. All complications were recorded prospectively. ResultsMean Oxford, Constant, Relative Constant and QuickDASH scores and percentage of disability for the plate and nail groups respectively were: 23.8 vs. 23.3, 59.7 vs. 60 6, 73.5 vs 79.3, 20.9 vs 21.0, 22.6 vs 22.6. Multivariate analysis did not show any significant difference in functional scores or quality of reduction: final unsatisfactory reduction on AP view, 30.3 vs. 36.7%; lateral view, 3.2 vs. 10.0%; greater tuberosity, 9.1 vs. 16.7%. Four-part fracture (P<0.05), frontal reduction defect at follow-up (P<0.05) or greater tuberosity defect (P>0.05) had negative impacts on functional scores. The complication rates corresponded to those in the literature and did not differ between the techniques (P=0.1901) except for three infections in the plate group. Discussion-ConclusionInternal fixation is the treatment of choice for 3- and 4-part fractures in non-osteoporotic patients. Although no difference was found in the present study between locking plate and intramedullary nailing, the former seems to be less well adapted and more aggressive. Type of studyRetrospective observational study. Level of evidenceLevel 4.

Delta III reverse shoulder arthroplasty in the treatment of complex 3- and 4-part fractures of the proximal humerus: 6 to 42 months of follow up

BackgroundThere is a growing tendency for complex proximal humerus fractures (PHF) in osteoporotic patients to be treated with reverse shoulder arthroplasty (RSA). It has been proposed that RSA has more benefits than other treatment options. The aim of our study was to investigate preoperative characteristics as well as clinical and radiological outcomes in patients with complex 3- or 4-part PHF who had undergone primary RSA.MethodsPatients with a minimum follow-up of 6 months who had undergone a primary RSA after 3- or 4-part PHF in the period between 2008 and 2011 were eligible for the study. Clinical records, X-rays and CT-scans were investigated and a clinical examination was performed. Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant-Murley score (CMS) were calculated. Sixteen patients were examined as part of the study. The mean follow-up was 20 months (range 6-42 months). According to Codman-Hertel classification we encountered 15 Hertel “12” and 1 Hertel “8” type fractures.ResultsThirty-two patients (27 female – 84.4%) with a mean age of 72 years underwent operations to treat complex 3- and 4-part fractures of the proximal humerus. Sixteen patients were reexamined. In 14 cases the dominant upper extremity was on the right, in 2 cases it was on the left, in 6 cases the right side was affected and in 10 cases the left side was affected. The mean CMS was 54.8 (range 18-95) and the mean DASH was 37.5 (range 2.9-81). A trend was established between the CMS and dominance of the affected shoulder. The CMS was better if the affected shoulder was on the non-dominant side (p-value 0.051). No statistical difference was noted between age and clinical outcome.ConclusionsOur mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. RSA can provide immediate relief and good shoulder function in elderly patients. Nevertheless, the question of longevity of these implants remains to be observed.

Meta-analysis of joint preservation versus arthroplasty for the treatment of displaced 3- and 4-part fractures of the proximal humerus

PurposeThis meta-analysis compares the clinical outcomes of joint preservation versus arthroplasty in the treatment of displaced proximal humerus fractures. MethodsMedline, CINAHL, and EMBASE were searched for studies published between 1970 and 2011 reporting outcomes of the treatment of 3- or 4-part proximal humerus fractures using the Constant–Murley score in skeletally mature patients. Randomised and cohort studies with ≥1-year follow-up were included. Two individuals independently extracted data, and study results were divided into subgroups based on type of treatment. ResultsA meta-analysis with meta regressions was performed on the mean Constant score. Of 610 total participants in the studies analysed, 340 were treated with joint-preserving techniques. The random-effects mean Constant score across all treatment types was 62.7 (95% CI, 61.6–63.9, P<0.001), with joint-preserving treatments demonstrating higher scores than arthroplasty (70 vs. 49, P<0.001). The studies displayed significant heterogeneity (Q statistic=516, P<0.001, I2=94.8). In the meta-regression analyses, Constant scores decreased significantly with increasing age, fracture severity, and rate of osteonecrosis (P<0.001). ConclusionsIn the existing literature, displaced proximal humerus fractures demonstrate improved Constant scores when treated with joint-preserving options. Age, fracture pattern, and complication rate are significant predictors of the Constant score independent of the selected treatment. Given the observed heterogeneity and variance in treatment techniques in the included studies, more comparative studies are needed to definitively recommend joint-preserving techniques versus arthroplasty for specific fracture patterns.

Complex Proximal Humerus Fractures Treated With Locked Plating Utilizing an Extended Deltoid Split Approach With a Shoulder Strap Incision

The goal of the study is to analyze the outcome and complications after locked plating of proximal humerus fractures with the extended deltoid split approach though a shoulder strap incision. Prospective. Tertiary care referral center. Fifty-two adult patients with a displaced 3 or 4 part proximal humerus fracture or fracture dislocation. Open reduction and locked plate osteosynthesis through an extended deltoid split approach using a strap incision. Electrophysiological assessment of axillary nerve function at 6 weeks and at 3, 6, and 12 months postoperatively in those patients in whom an abnormality was detected postoperatively. Functional outcome measurement using normalized Constant scores at 6 and 12 months. Other measures include radiological assessment and complications. Traction injury to the anterior part of the axillary nerve was electrically evident but not clinically apparent in 4 patients. The normalized Constant score continued to show significant improvement 1 year post surgery, 67.3 ± 11.3 at 6 months and 80.2 ± 7.7 at 1 year (P = 0.001)). Union was obtained in all patients. Varus/valgus/tuberosity malreductions were seen in 8 patients. Loss of reduction was seen in 2 patients. Two patients had radiological evidence of avascular necrosis at 1-year follow-up. Locked plating of proximal humerus fractures through an extended deltoid split approach using a shoulder strap incision provides satisfactory outcomes. Axillary nerve injury is the only limitation of the approach and can be minimized with careful identification and protection of the nerve throughout the procedure. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Functional outcome of closed fractures of proximal humerus managed by Joshi’s external stabilizing system

Background:Proximal humeral fractures account for 4–5% of all fractures; most of them involving elderly and osteoporotic people. 1 51% of such fractures are displaced. Two Fractures with minimal displacement, regardless of the number of fracture lines, can be treated with closed reduction and early mobilization, but anatomical reduction in displaced fractures is difficult to obtain and the incidence of pseudarthrosis is high 3-5. We evaluated the functional results of closed Neer's 2- and 3-part proximal humerus fractures treated by Joshi's external stabilizing system.Materials and Methods:Sixteen patients with proximal humeral fractures were managed from 2008 to 2010 by Joshi's stabilizing external fixation. They were 10 males and 6 females, with a mean age of 57.5 years. Based on Neer's classification, there were eleven 3-part fractures and five 2-part fractures. The mechanism of injuries included seven road traffic accidents and nine fall. Shoulder mobilization exercises were started within 1 week after stabilization with JESS. External fixation was removed after the evidence of union (6–8 weeks). Pain was evaluated by visual analogue scale (VAS) and shoulder range of motion was evaluated by Constant Scoring System. Followup was done at 4 weeks, 8 weeks, 12 weeks, and then at every 4 weeks.Results:Mean followup was of 20.5 months (range 9-30 months). Postoperative mean VAS score and Constant Score of patients was 2.1 (±0.73) and 78.1 (±9.61) at an average followup of 6 months. Mean duration for union was 6.5 (±1.18) weeks. One case of K-wire loosening and one case of pin tract infection were the complications noted.Conclusion:External fixation by JESS is an alternative option to treat Neer's 2 and 3 part proximal humerus fractures with good results.

Long term results of percutaneous fixation of proximal humerus fractures

Background:Proximal humerus fracture in elderly osteoporotic patients usually leads to severe displaced and multifragmentary fractures. Associated comorbidities may limit surgical options and conservative treatment is commonly indicated, however, with variable results. In most cases, surgery is the treatment of choice in order to restore anatomical integrity, and allow early functional recovery. Several techniques were used over the years, each with specific indication. Percutaneous pinning after closed reduction, a mini-invasive technique and fixation by use of K-wires is not preferred commonly. We present our experience with this approach, focusing on its indications and advantages.Patients and Methods:A study group of 41 consecutive patients with a mean age of 65.5 years were evaluated clinically (VAS, Constant-Murley score, range of motion), and with radiological analysis: 35 patients finally completed a minimum followup of 24 months.Results:K-wires were removed after a mean interval of 4 weeks. Clinical and radiographic healing occurred in a mean time of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score of 87.6 points, mean VAS of 2.3. In 33 patients, the reduction was considered satisfactory. In two cases, reduction was poor, but the patients however presented acceptable functional outcome.Conclusions:Percutaneous pinning may represent a suitable option of treatment for 2-or 3-part proximal humerus fractures in selected subjects.

Open Reduction and Internal Fixation (ORIF) of Complex 3- and 4-Part Fractures of the Proximal Humerus

Treatment of complex fracture patterns of the proximal humerus continues to be a challenging and controversial clinical scenario. The aim of this study was to report on the outcomes of complex displaced 3- and 4-part fractures of the proximal humerus treated with locked plating and compare the functional results of patients on the basis of age at time of injury. A retrospective review was completed to identify patients whom had sustained a 3- or 4-part fracture of the proximal humerus (Neer classification), treated surgically with locked compression plating. Patients were recruited for a final follow-up, with clinical (Constant and Disabilities of the Arm, Shoulder, Hand [DASH] scores) and radiographic outcome analysis. Results were compared (t test and Wilcoxon test) with fracture type (3- vs 4-part) and patient age at time of fracture (<65 years vs >65years) as the primary outcome measure. The presence or absence of a complication and presence or absence of a concomitant osseous injury at the time of presentation were evaluated as secondary outcome measures, in regard to overall functional results of the treatment in question. Complications were defined as posttraumatic osteoarthritis, avascular necrosis of the humeral head, and screw cutout with chondrolysis. The null hypothesis being that age of the patient at the time of injury would not greatly affect functional outcome measurements. Forty-five fractures were identified in 45 patients, with 31 three-part fractures and 14 four-part fractures, and 17 patients were available for final follow-up (9 three-part and 8 four-part). Twelve patients were identified as under the age of 65 years and were compared with 5 patients who were identified as older than 65 years of age. The relative Constant score, at final follow-up, for those under the age of 65 was 88.58, while the score for those above the age of 65 was 82.5. In a similar fashion, the DASH score for those younger than 65 was 11.67, while the score for those older than 65 was 12.5. Neither the Constant score nor the DASH score differed in a statistically significant manner, when comparing patients who were younger than 65 to those older than 65 years of age. The current series of fractures was able to demonstrate similar and satisfactory outcomes following locked plating treatment of complex 3- and 4-part proximal humerus fractures in younger patients and patients older than the age of 65, while still accepting the null hypothesis.

Functional Outcomes for Surgically Treated 3- and 4-part Proximal Humerus Fractures

Surgical treatment of 3- and 4-part proximal humeral fractures remains challenging. This study retrospectively evaluated functional outcomes of locked plate fixation vs hemi-arthroplasty in 57 patients with 3- and 4-part proximal humerus fractures from 2003 to 2005 with a mean follow-up time of 35 months (range, 15.7-52.7 months). Mean patient age was 56.9 years (range, 29-81.7 years) for the open reduction and internal fixation group (n=42) and 66.4 years (range, 38.1-90 years) for hemiarthroplasty group (n=15). All 57 patients completed the American Shoulder and Elbow Surgeons score, the Simple Shoulder Test, the Euroqol EQ-5D, [corrected] and the visual analog pain scale. Range of motion, the Constant Score, and the UCLA Shoulder score were used to evaluate a subset of 33 patients. Forty-one patients in the open reduction and internal fixation group achieved union, and 1 had symptomatic avascular necrosis requiring subsequent hemiarthroplasty. Two patients had implant removal for impingement symptoms. In the hemiarthroplasty group, there was 1 revision for a loose prosthesis. The American Shoulder and Elbow Surgeons score (P=.023), Simple Shoulder Test (P=.012), patient satisfaction (P=.034), Constant Score (P=.008), Kelsh Adjusted Constant Score (P=.015), UCLA Shoulder score (P=.01), and range of motion (forward flexion, P=.002; abduction, P=.001) were significantly better in the open reduction and internal fixation group than the hemiarthroplasty group. No significant differences between the groups existed in terms of SF-12 (physical, P=.118; mental, P=.134), Euroqol EQ-5D [corrected] (P=.169), or visual analog pain scale scores (P=.135), but all trended toward better with open reduction and internal fixation.

Bilancio e prospettive del trattamento chirurgico delle fratture a tre-quattro parti dell’epifisi prossimale dell’omero

ORIF of displaced unstable 3–4 part proximal humerus fractures remains a challenge due to poor bone quality and the difficulties related to reduction and stabilisation of medially unstable fractures with comminution of the humeral calcar. During the last two decades different techniques have been utilised (percutaneous reduction and pinning, open reduction and minimally invasive stabilisation with pins, screws and osteosutures, locking humeral plates, allografts or osseous substitutes as adjuvant in stabilisation and humeral head revascularisation).

A systematic review of locking plate fixation of proximal humerus fractures

Purpose Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates. Methods The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias. Results Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%. Discussion Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.

Internal plating versus humeral head replacement for 3- and 4- part fractures of proximal humerus in senior patients

目的 比较采用钢板内固定术与人工肱骨头置换术治疗老年肱骨近端三、四部分骨折的临床疗效.方法 2004年3月至2007年9月,共收治40例老年肱骨外科颈三、四部分骨折患者,男15例,女25例;年龄70～81岁,平均73.5岁.采用骨折开放复位钢板内固定术(内固定组)21例,男8例,女13例;平均年龄73.2岁.行人工肱骨头置换术(关节置换组)19例,男7例,女12例;平均年龄73.7岁.比较两组患者的手术时间、失血量、开始主动活动的时间及术后并发症的发生率等.结果 内固定组和关节置换组的手术时间平均分别为(120±30)、(90±20)min,术中出血量平均分别为(500±150)、(400±100)mL,术后开始活动时间平均分别为(42±14)、(21±3)d,差异均有统计学意义(P＜0.05).两组患者分别有7例、6例发生并发症,优良率分别为81.0%、84.2%,两组比较差异均无统计学意义(P＞0.05).结论 对于老年肱骨近端三、四部分骨折,采用人工肱骨头置换术治疗具有较好的临床效果。

Locked Plating of 3- and 4-Part Proximal Humerus Fractures in Older Patients: The Effect of Initial Fracture Pattern on Outcome

Locked Plating of 3- and 4-Part Proximal Humerus Fractures in Older Patients: The Effect of Initial Fracture Pattern on Outcome