Proximal Humerus Internal Locking System Research Articles

Comparison of optimal screw configurations in two locking plate systems for proximal humerus fixation - a finite element analysis study

BackgroundManagement of proximal humerus fractures is challenging, especially in elderly. Locking plating is a common surgical treatment option. The Proximal Humerus Internal Locking System (plate-A) has shown to lower complication rates compared to conventional plates, but is associated with impingement risk, which could be avoided using Peri-articular Proximal Humerus Plate (plate-B). Nevertheless, biomechanical performance and optimal screw configuration of plate-B is unknown. The aim of this study was to evaluate different screw configurations of plate-B and compare with plate-A using finite element analyses. MethodsTwenty-six proximal humerus models were osteotomised to create unstable three-part fractures, fixed with either of the two plates, and tested under three anatomical loading conditions using a previous established and validated finite element simulation framework. Various clinically relevant screw configurations were investigated for both plates and compared based on the predicted peri-implant bone strain, being a validated surrogate of cyclic cut-out failure. FindingsBesides increasing the number of screws, the placement of the posterior screws in combination with the calcar screw in the plate-B significantly decreased the predicted failure risk. Generally, plate-A had a lower predicted failure risk than plate-B. InterpretationThe posterior and calcar screws may be prioritized in plate-B. Compared to plate-A, the more distal positioning, less purchase in the posterior aspect and a smaller screw spread due to not fitting of the most distal calcar screw in most investigated subjects led to a significantly higher predicted failure risk for most plate-B configurations. The findings of the simulations study require clinical corroboration.

Anterior minimally invasive plating osteosynthesis using reversed proximal humeral internal locking system plate for distal humeral shaft fractures.

To describe the surgical application of anterior minimally invasive plating osteosynthesis (MIPO) using reversed proximal humerus internal locking system (PHILOS) plate for multifragmentary distal humeral shaft fractures. Twelve patients with distal humeral shaft fractures (type 12B, n = 6 and type 12C, n = 6) were operated on by anterior MIPO and reversed PHILOS plate fixation. The amount of intact bone in the distal fragment was measured by fracture-to-coronoid distance (FCD). Data of the postoperative alignment, complications, union time, and clinical outcomes were collected. The mean time for fractures to unite in all patients was 14.8weeks (range 12-22). There was no perioperative complication. The mean FCD was 4.8cm (range 2.1-8.1). The mean coronal angulation was 3.4° (range 0-9), and the mean sagittal angulation was 1° (range 0-5). All patients had excellent UCLA shoulder score and MEP score results, and the mean range of elbow motion was 140° (range 130-145). Anterior MIPO using reversed PHILOS plate is safe and effective for multifragmentary fractures of the distal humeral shaft even in a fracture with a length of intact bone above the coronoid fossa of only 2cm.

Bilateral symmetrical anterior fracture dislocation of shoulder

<p>The incidence of simultaneous bilateral shoulder joint dislocation is rare and is almost always posterior usually caused by violent muscle contraction as in patients with seizure disorders or who experience electric shock or undergo electroconvulsive therapy. simultaneous bilateral fracture-dislocation is even rarer, with a few cases reported in the literature. We report an unusual case with dislocation of the both shoulder joints in anterior direction after a seizure episode, With symmetrical unifocal 2-part extraarticular vertical fracture of proximal end segment of humerus (11A3) both sides. Although there have been a few reports of bilateral symmetrical fracture dislocations of the shoulder in the past, an injury pattern resembling our case has, to the best of our knowledge, not been described in the literature so far. Our report describes regarding the mechanism of injury in a case of a bilateral symmetrical anterior fracture dislocation following a seizure episode that treated with open reduction internal fixation using proximal humerus internal locking system (PHILOS). At final follow-up, the patient had healed fractures, painless near normal range of motion.</p>

Results of surgical management of displaced or complex proximal humeral fractures with proximal Humerus internal locking system: A prospective study of 55 cases

Background: The optimal treatment of proximal humeral fractures remains always challenging and controversial. The purpose of this prospective study was to evaluate the functional outcome of proximal humerus internal locking system (PHILOS) plate fixation for displaced or complex proximal humeral fractures and to establish the influencing factors of an unfavourable outcome. Materials and Methods: After obtaining approval from institutional ethics committee, 55 patients with the displaced proximal humeral fractures were managed by open reduction and PHILOS plate fixation through delto-pectoral approach and as per standard protocol. The results of follow-ups were analysed radiologically and clinically, using the “Constant and Murley scoring system” at once in a month for first three months, once in three months for next six months and once in six months thereafter upto 2 years post-operatively. Results: In the present study, out of 55 patients, clinical results were excellent in 50.9%, good in 21.8%, fair in 16.4% and poor in 10.9% patients. Radiological union was achieved in all patients, including two cases of mal-union and one case of delayed union. Post- traumatic frozen shoulder (7 cases), secondary arthritis (5 cases), secondary screw penetration (3 cases), and AVN humeral head (3 cases) were the main complications observed in this study during 2 years of follow-ups, which were treated accordingly. Conclusion: Pre-contoured PHILOS plate preserves shape of humeral head, provides angular stability, facilitates to restore the medial column and prevent secondary varus collapse in severe comminuted and osteoporotic proximal humeral fractures. With proper patient selection, PHILOS plate provides favourable clinical and radiological outcome with acceptable complication rates.

Functional outcome of proximal humerus fracture treated with proximal humerus locking compression plate in adults: A prospective study

Background: Proximal humerus fractures are common and debilitating injuries and their incidence is increasing especially in elderly. Treatment of unstable, displaced, and comminuted fractures of the proximal humerus remains a challenging issue and significant controversy exists regarding the best method of treating these fractures. Various operative procedures are carried out nowadays, with the recent trend being internal fixation using locking plates. The present study is undertaken to evaluate the functional outcome of proximal humerus fractures treated by proximal humerus internal locking system (PHILOS) plate. Methods: The proposed study is a prospective study conducted between May 2017 to June 2019 in a tertiary care center in Bangalore. In this study 30 post traumatic cases of proximal humeral fractures (Neers type 2, type 3) were treated by ORIF with proximal humerus internal locking system (PHILOS) plate and functional and radiological outcome was assessed using Constant score at 6weeks, 3months, 6months and 1year post-op. Results: Majority of the patients in the study were males (63.3%), RTA being the commonest mode of injury in young population and fall being most common mode in elderly. 11(36.7%) and 19(63.3%) patients had Neers 2 part and 3 part fractures respectively. Radiologically, time to union ranged between 12 to 18 weeks. Mean constant score at one year follow-up was 73.63 and it was found that there was a significant reduction in favorable outcome with increase in age (p< 0.001). Conclusion: PHILOS plating has a good functional outcome for proximal humerus fractures. Accurate anatomical reduction and early fracture fixation are essential for good functional outcome. A proper surgical technique will minimize complications and an aggressive rehabilitation regime will ensure the best possible functional outcome for the patient.

Use of proximal humerus internal locking system plate in proximal humerus fractures and its relation with the functional outcome

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Proximal humerus fractures are the fractures occurs at or proximal to the surgical neck of the humerus, which accounts for 7% of all fractures and 80% of all humeral fractures. Now a days most of these fractures are managed with internal fixation because of better availability of anatomical plates. The aim was to assess the functional outcome and complications of proximal humerus fractures treated with proximal humerus internal locking system (PHILOS).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a prospective study of 30 patients with two, three, and four parts proximal humerus fractures treated with proximal humerus internal locking sysyem from 2016 to 2018 with 25 to 80 years of age in a tertiary care hospital. Functional outcome is assessed by using constant murley shoulder scoring system.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Functional outcome as per constant score, 10 patients (33%) got excellent outcome, 06 patients (20%) got very good outcome, 07 patients got (23%) good outcome, 05 patients got (17%) fair outcome and 02 patients got (07%) poor outcome. Complications observed were superficial infections, implant failure and axillary nerve neuropraxia.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Open reduction and internal fixation by using PHILOS is the ideal method in treating displaced proximal humerus fractures mainly in two and three part proximal humerus fractures which provides stable fixation and less complications.&lt;/p&gt;

Prospective observational study evaluating the outcome of a fixed angle plate (proximal humerus internal locking system) in proximal humerus fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Proximal humerus fractures are common among elderly. The present study assesses the functional outcomes of fixed angle plate (proximal humerus internal locking system (PHILOS)) in fractures of proximal humerus.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 30 participants aged ≥18 years with proximal humerus fracture (2, 3 and 4 part) who underwent PHILOS fixation were enrolled. Undisplaced, open, severely comminuted, metastatic, and pathological fractures and with associated head injury and neurovascular injuries wew excluded. Clinical and radiological evaluation were done pre and post-operatively. Intraarticular extent of fracture geometry was assessed using 3-dimensional computed tomography. Participants were managed preoperatively with analgesics and shoulder immobilizer followed by preanesthetic check-up and routine investigations and surgery was done once participants were stable. Sample size was calculated assuming excellent or satisfactory results in 80% participants 6 months after surgery, relative precision of 20%, α of 5% and 10% attrition rate. Institutional ethics committee approved the study and written informed consent was obtained from all study participants.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean age of study participants was 62.9 (14.9) years and were predominantly females (66.6%, n=20). No significant difference between type of fracture and duration of recovery was observed (p=0.4). 30% participants had post-operative complications, stiffness was the most common (13.3%, n=4) complication. 76.6% (n=23) participants had good functional outcomes. Significant correlation between type of fracture and NEER score was observed (p&amp;lt;0.0001).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; PHILOS is a preferential implant in proximal humerus fractures due to angular stability, particularly in comminuted fractures in younger patients, and osteoporotic fractures in elderly, thus allowing early mobilization and satisfactory final functional outcome. &lt;/p&gt;

Internal Fixation of Proximal Humerus Fracture by PHILOS Plate

Background: Fractures of the proximal humerus are relatively common, accounting for about 5% to 9% of all fractions. Majority of undisplaced proximal humeral fractures can be treated with a sling immobilization and physical therapy. However, approximately 20% of displaced proximal humeral fractures require surgery. Objective: The aim of the current study was to assess the expected outcomes and complication rate of proximal humerus fractures treated with Proximal Humerus Internal Locking System (PHILOS) plating. Patients and Methods: This prospective study included a total of 15 patients with fracture of the proximal humerus attending at Department of Orthopedic Surgery, Al-Azhar University Hospitals. This study was conducted between January 2018 to October 2018. All cases were surgically managed by fracture fixation procedures (PHILOS). The follow up period of the cases is 6 months. Results: From analysis of the literature concerning the use of PHILOS plates, our results were satisfying in terms of functional recovery, with Constant Scores 73.67 that range between (48%–94%). Data from our survey show that most of patients were satisfied. We have noticed that limited functional recovery was usually caused by incorrect or delayed rehabilitation. The complication rate in our study (26.66%) is comparable to the literature, where the most recent studies report complication rates between 32 and 50%. Conclusion: More accurate length measurement and shorter screw selection should prevent primary screw perforation.

Cement augmentation of the proximal humerus internal locking system in elderly patients: a multicenter randomized controlled trial

IntroductionCement augmentation of the proximal humerus internal locking system (PHILOS) screws might reduce complication rates in osteoporotic bones. This study compared the risk of mechanical failure during the first year after PHILOS™ treatment of proximal humerus fractures (PHF) without (control group) and with (augmented group) screw augmentation. Secondary objectives were to report shoulder functions, quality of life (QoL), adverse events (AEs), and reoperation rates.Materials and methodsThis multicenter randomized trial enrolled patients aged ≥ 65 years with displaced/unstable PHF from eight European centers. Randomization was performed during surgery through sealed opaque envelopes. Mechanical failures were assessed by two independent reviewers via radiographs, shoulder function by Quick DASH, SPADI, and Constant Murley scores, and QoL by EQ-5D. Follow-ups were planned at postoperative 6 weeks, 3, 6, and 12 months.ResultsThe preliminary analysis of 6-week radiographs of the first 59 enrolled patients suggested a mechanical failure rate lower than expected and the difference between groups was too small to be detected by the planned sample size of 144. The trial was prematurely terminated after 67 patients had been enrolled: 34 (27 eligible) in the control group and 33 (29 eligible) in the augmented group. Follow-ups were performed as planned. Nine patients had mechanical failures and the failure rates (95% CI) were: augmented group, 16.1% (5.5; 33.7); control group, 14.8% (4.2; 33.7); the relative risk (95% CI) for the augmented group was 1.09 (0.32; 3.65) compared to the control group (p = 1.000). No statistically significant differences in shoulder function, QoL, and AEs were observed between study groups at 1 year. Nine patients (15.8%) underwent a revision.ConclusionsDue to premature termination, the study was underpowered. A larger study will be necessary to determine if cement augmentation lowers the risk of mechanical failure rate.

Treatment of proximal humeral fractures with proximal humeral locking system plate via an intertubercular sulcus approach

To observe the effect of proximal humerus internal locking system (PHILOS) plate in the treatment of Neer 2 and 3 part fractures of proximal humerus through tuberosity approach. From July 2015 to January 2018, 15 cases of proximal humerus Neer 2 and 3 fractures were treated with PHILOS plate through intertubercular sulcus approach. There were 7 males and 8 females. The age ranged from 23 to 67 years old, with an average of 46 years old. There were 5 cases on the left side and 10 cases on the right side (including 7 cases of Neer 2 partial fracture and 8 cases of Neer 3 partial fracture). X-ray films and CT were taken before and after operation to assess fracture location and fracture healing. Clinical evaluation included Constant-Murley shoulder function score and operative complications. All 15 patients were treated with the PHILOS. Constant-Murley score was used to evaluate shoulder function after operation. All the 15 cases were followed up, and the duration ranged from 14 to 36 months. All the fractures healed and the healing time ranged from 14 to 26 weeks, averaged 19.1 weeks. There were no complications such as humeral head necrosis, axillary nerve injury and fracture nonunion after operation. At the 3rd month after operation, the shoulder function score of Constant-Murley ranged from 72 to 94 points, with an average of 81 points; 2 cases got an excellent result and 13 good. The PHILOS plate for the treatment of proximal humerus fractures has the advantages of simple operation, small injury and quick recovery of shoulder joint function.

Pre-contouring long helical plate of proximal humerus internal locking system aided by 3D-printing technique in minimally invasive plate osteosynthesis for metadiaphyseal fractures of the proximal humerus: a cadaveric study and clinical experience

Objective To identify the anatomic advantages of pre-contouring long helical plate of proximal humerus internal locking system (PHILOS) aided by 3D-printing technique in minimally invasive plate oseoynthesis (MIPO) for metadiaphyseal fractures of the proximal humerus. Methods Firstly in a cadaveric study, 12 fresh frozen samples of upper extremity were divided into 2 equal groups: 6 in a Synbone group and 6 in a 3D-printing group. Long 10-hole PHILOS plates were pre-contoured helically according to Synbone humerus models in the Synbone group but according to 3D-printing humerus models in the 3D-printing group. All these helical plates were fixed onto the cadaveric humerus using MIPO technique respectively. The horizontal distances between the radial nerve and the lateral side of the plate were measured at the point where the radial nerve penetrates the muscular septum, at the 6th hole on the plate and at the distal end of the plate; the distance between the medial side of the distal plate and the upper arm neurovascular bundle was also measured. Finally, the full lengths of all these cadaveric humeri were measured. Secondly, on the basis of the anatomic study, 16 patients with metadiaphyseal fracture of the proximal humerus were treated at Department of Orthopedic Surgery, The Sixth People’s Hospital of Shanghai from February 2013 to March 2016, using the same MIPO technique and the same long 10-hole PHILOS plates pre-contoured helically on the 3D printing models which were mirrored on the humerus on the healthy side of the patients. They were 4 men and 12 women, aged from 59 to 87 years (mean, 71.0 years). By the AO/OTA classification, 10 cases were type B and 6 type C. The fracture line involved the proximal humerus in 7 cases. Postoperative complications were followed up. At the final follow-up, the shoulder function was assessed according to the Constant-Murley score and the elbow function according to the Mayo Elbow Performance Score (MEPS). Results By the anatomic measurement, the full length of cadaveric humerus averaged 30.17±1.93 cm in the Synbone group and 29.75±2.17cm in the 3D-printing group, showing no significant difference (P>0.05). The horizontal distances between the radial nerve and lateral side of the plate at the point where the radial nerve penetrates the muscular septum, at the 6th hole on the plate and at the distal end of the plate in the Synbone and 3D-printing groups were, respectively, 11.50±0.92 mm versus 17.87±1.88 mm, 6.90±1.78 mm versus 14.83±1.50 mm, and 5.14±1.14 mm versus 8.36±1.27 mm, all showing significant differences between the 2 groups (P 0.05). The clinical observation found no iatrogenic nerve injury. The 16 patients were followed up for an average of 25.3 months (range, from 24 to 38 months). All fractures got united uneventfully. At the final follow-up, their Constant-Murley scores averaged 77.6 points and their MEPS 96.5 points. Conclusion The risk of iatrogenic injury to the radial nerve can be lowered when 3D-print technique is applied for helical pre-contouring of long PHILOS plate in the MIPO for metadiaphyseal proximal humeral fractures, leading to satisfactory clinical results. Key words: Humeral fractures; Fracture fixation, internal; Anatomy; Clinical trial; 3D printing technology

Results and analytical outcomes of proximal humerus plating in adults with proximal humerus fracture

Fracture of proximal humerus is the second most common fracture of the upper extremity, following distal forearm fractures. Aim of the present study was to evaluate the efficacy of proximal humerus internal locking system (PHILOS) plate fixation for proximal humerus fractures. Functional outcomes of 12 men and 18 women aged 22 to 78 (mean, 58) years who underwent PHILOS plate fixation for proximal humeral fractures were reviewed. Indications for surgery were 2 part (n=9), 3 part (n=14) or 4-part (n=7) closed proximal humeral fractures with angulation of more than 45 degrees or displacement of more than 1 cm. Functional outcomes and shoulder range of movement were assessed based on the Constant scoring system. All patients will be followed up at monthly intervals for 6 months. During this period patient, will be motivated for physiotherapy and gradual normal use of the affected limb. Fracture union will be assessed clinically and radiologically. In our study of fracture proximal humerus union in most of the cases (24) occurring between 10- 14 weeks. Range of union time was 8 to 18 weeks. one case of avascular necrosis of head occur in our case. In out of 30 cases excellent result in 7 cases, Good in16 cases Satisfactory in 5 cases and Poor in 2 cases were obtained. The PHILOS plate fixation is effective treatment for proximal humeral fractures particularly in osteoporotic bones.

Proximal humerus internal locking system combined with allogeneic femoral head bone graft for osteoporotic proximal humeral fractures in the elderly

Objective To evaluate the efficacy of proximal humerus internal locking system (PHILOS) combined with allogeneic femoral head bone graft for the treatment of osteoporotic proximal humerus fractures in the elderly patients. Methods A total of 36 osteoporotic proximal humerus fractures were analyzed retrospectively which had been treated at Department of Orthopaedics, Traditional Chinese Medicine Hospital of Xinjiang Uygur Autonomous Region from April 2015 to April 2017. They involved 14 men and 22 women, aged from 60 to 78 years(average, 67 years). By the Neer classification, 20 cases were two-part fractures, 11 three-part fractures and 5 four-part fractures. They were all treated by PHILOS plating combined with allogeneic femoral head bone grafting. The outcomes were assessed using Neer evaluation system for shoulder function. Results All the 36 cases were followed up for 3 to 18 months (average, 12 months). All the incisions healed postoperatively by the first intention, with no postoperative infection, nonunion, humeral head varus, screw cut-out, humeral head necrosis, or loosening of implants. Clinical healing of the fractures was achieved after 8 to 24 weeks (average, 12 weeks). According to the Neer evaluation, shoulder function was excellent in 18, good in 15 and poor in 3 cases. Conclusion In the treatment of osteoporotic proximal humerus fractures in the elderly, combination of PHILOS plating and allogeneic femoral head bone grafting can effectively prevent such postoperative complications as humeral head varus, screw cut-out and loosening of implants. Key words: Humerus fractures, proximal; Bone plate; Osteoporosis; Bone graft

Failure Analysis of PHILOS Plate Construct Used for Pantalar Arthrodesis Paper II—Screws and FEM Simulations

A fractured stainless steel 3.5 mm proximal humerus internal locking system (PHILOS) plate and screws were investigated in this paper. This plate was used for ankle arthrodesis of a 68-year-old female with a right ankle deformity. Both the plate and screws were considered in this investigation. Optical and scanning electron microscopes (SEM) were used to document fracture surface characteristics, such as extensive scratching, plastic deformation, rubbed surfaces, discoloration, and pitting, along with cleavage, secondary cracking, deposits of debris, striations, and dimples. Indications of these features show that the plate failed by corrosion fatigue, however, overloading separated the screw(s) in two parts. Radiographic evidence shows that the screws failed ahead of the plate from the proximal end. Three-dimensional models of the plate and the screws: cortical, locking, and cannulated, were constructed using Solidworks and imported in ANSYS Workbench 16.2 to simulate the loading conditions and regions of stress development. Statistical analysis was conducted to understand the impact of different factors on the maximum von Mises stresses of the locking compression plate. These factors were the load, screw design pattern, coefficient of friction between the plate and screws, and cortical screw displacement. In summary, the finite element simulation of the plate validates the fractographic examination results. The following observations were made: (a) as the angle between the screws and the plates increased, the von Mises stresses increased in the cortical screws; and (b) the stress in the locking screws was lower than that of the cortical screws, which may be due to locking the screws with fixed angles onto the plate. Finally, fractographic examination of the cortical and locking screws supports the mechanism of corrosion-fatigue fracture from crack initiation sites, pits, due to the presence of inclusion bodies for this material (ASTM standards F138-03 and F139-03) documented for the plate in Paper I.

Failure Analysis of PHILOS Plate Construct Used for Pantalar Arthrodesis Paper I—Analysis of the Plate

The failure of a proximal humerus internal locking system (PHILOS) used in a pantalar arthrodesis was investigated in this paper. PHILOS constructs are hybrids using locking and non-locking screws. Both the plate and the screws used in the fusion were obtained for analysis. However, only the plate failure analysis is reported in this paper. The implant had failed in several pieces. Optical and scanning electron microscopic analyses were performed to characterize the failure mode(s) and fracture surface. The chemical composition and mechanical properties of the plate were determined and compared to controlling specifications to manufacture the devices. We found that equivalent tensile strength exceeded at the locations of high stress, axial, and angular displacement and matched the specification at the regions of lower stress/displacement. Such a region-wise change in mechanical properties with in vivo utilization has not been reported in the literature. Evidence of inclusions was qualitatively determined for the stainless steel 316L plate failing the specifications. Pitting corrosion, scratches, discoloration and debris were present on the plate. Fracture surface showed (1) multi-site corrosion damage within the screw holes forming a 45° maximum shear force line for crack-linking, and (2) crack propagation perpendicular to the crack forming origin that may have formed due to the presence of inclusions. Fracture features such as beach marks and striations indicating that corrosion may have initiated the crack(s), which grew by fatigue over a period of time. In conclusion, the most likely mechanism of failure for the device was due to corrosion fatigue and lack of bony in-growth on the screws that may have caused loosening of the device causing deformity and pre-mature failure.

Assessment of Screw Length of Proximal Humerus Internal Locking System (PHILOS) Plate for Proximal Humeral Fractures Using Three-Dimensional Computed Tomography Scan

BackgroundScrew perforation and varus collapse are common complications of treatment with a PHILOS (proximal humerus internal locking system) plate for proximal humerus fractures, which are associated with improper screw length selection and lack of medial column support. The purposes of this study were: (1) to measure the proper length of periarticular screws of the PHILOS plate in the humeral head, and (2) to determine what factors influence the screw length and implantation of the inferomedial support screw.Material/MethodsComputed tomography (CT) images of the normal proximal humerus in 134 cases were retrospectively reviewed. The length of periarticular screws was measured using three-dimensional (3D) techniques. Intraobserver and interobserver reliability of measurement were evaluated using intraclass correlation coefficients (ICCs). Sex and body height influences on screw length and implantation of the inferomedial screw were analyzed.ResultsAll measurements had excellent agreement (ICC>0.75). The screw length and implantation rate of the inferomedial screw were greater in males than in females. Positive correlations were observed between body height and screw length and implantation of the inferomedial screw (all P<0.001).ConclusionsThe screws were longer and the implantation rate was higher for inferomedial screws in males than in females, and were positively correlated with body height. Our data can be used as a reference for surgeons to reduce the number of times screws are changed intraoperatively and to reduce operation duration and minimize use of intraoperative fluoroscopy for proximal humerus fractures treated with the PHILOS plate.

Comparison of open reduction internal fixation with proximal humerus interlocking system and close reduction and pinning with K-wire in proximal humeral fracture

Introduction: Fracture of the proximal humerus represents the second most common fracture in upper extremity. The indications of surgery continue to expand due to improvement in internal fixation techniques. Aim: This study aimed to compare the result of open reduction internal fixation with proximal humerus interlocking system and close reduction and pinning with K-wire in these fractures. Materials and Methods: This study included 48 cases which were divided into two groups by randomized controlled trial type of study design, 24 patients (Group A) were operated with proximal humerus internal locking system (PHILOS) and 24 patients (Group B) with percutaneous K-wire fixation. All the 48 patients were followed up for a mean duration of 11 months. Final evaluation was done according to Neer's (1970) criteria. Results: All fractures united with an average of 10.34 weeks. Union time between the groups was statistically insignificant. In Group A, 83.33% of cases had favorable results against 50.0% of Group B and difference was significant. In Group A, mean Neer's score was 86.0 and in Group B it was 77.7 and difference was significant. In Group A, mean Neer's score for range of motion (ROM) was 20.75 and in Group B it was 17.25 and difference was significant. Ten complications (subacromial impingement-1, screw perforation-1, infection-1, malunion-2, stiff shoulder-3, and pain in shoulder-2) were seen in six patients (25%) treated with PHILOS and 17 complications (K-wire migration-2, infection-2, malunion-4, stiff shoulder-6, and pain in shoulder-3) were seen in 10 patients (41.1%) fixed with K-wire. Conclusion: In patients of 2-part and 3-part displaced proximal humerus fractures, results are almost equivocal. However, mean Neer's score for ROM was significantly more in patients treated with PHILOS. In 4-part fracture and patients of age >50 years, results of PHILOS are significantly better than K-wire.

Treatment of Proximal Humerus Fractures using PHILOS Plate.

Treatment of proximal humerus fractures always holds a dilemma for the treating surgeon. To assess the functional outcome of proximal humerus fractures treated with Proximal Humerus Internal Locking System (PHILOS) plating. Fifty three consecutive patients were treated with PHILOS plating between August 2013 and August 2014. The inclusion criteria were skeletally matured patients with closed fracture proximal humerus with displacement >1 cm and varus angulation of >450. Severely comminuted fractures, open fractures and valgus impacted fractures were excluded from the study. The outcome was assessed using Neer's scoring system. The average age was 54.3±5.8 years. As per the Neers classification system, there were 6 (11.32%) 1-part, 19 (35.85%) 2-part, 17 (32.085) and 11 (20.75%) 3 and 4-part fracture respectively. Average surgical duration was 94±10.2 minutes. Radiological union was seen at 12±4.6 weeks. There were 2 (3.77%) cases of varus collapse. Three (5.66%) cases had screw back out, which was later revised and had a favourable outcome. As per the Neer's scoring system, 7 (13.21%) cases had excellent results, 37 (69.81%) had satisfactory, 6 (11.32%) had unsatisfactory while 3 (05.66%) cases had poor outcomes. PHILOS plating has a good functional outcome. However, proper patient selection, thorough knowledge of the anatomy and biomechanical principles are the pre-requisites for a successful surgery.

Minimally invasive plate osteosynthesis for proximal humeral fractures.

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

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