Surgical Treatment of Neer Group VI Proximal Humeral Fractures Retrospective Comparison of PHILOS (R) and Hemiarthroplasty

Department of General Surgery, Trauma Division, Hospital Zurich-Triemli, Birmensdorferstrasse 497, CH-8063, Zurich, Switzerland.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 12/2011; 470(7):2035-42. DOI: 10.1007/s11999-011-2207-1
Source: PubMed


Neer Group VI proximal humeral fractures often are related to persistent disability despite surgical treatment. We retrospectively compared the outcome after open reduction and internal fixation with the PHILOS(®) plate or primary hemiarthroplasty in patients with Neer Group VI fractures focusing on complications, shoulder function, health-related quality of life (SF-36), and potential risk factors for complications.
The aim of this study was to compare the PHILOS(®) plate with primary hemiarthroplasty for treatment of specific Neer Group VI fractures. We asked whether (1) both procedures have comparable clinical and radiologic complication rates; (2) one procedure is superior in terms of revision rate; (3) objective and subjective shoulder function (Constant-Murley score) and health-related quality of life (SF-36) were comparable in both groups at final followup; and (4) there are clinical or radiologic predictors for complications in any group?
Between 2002 and 2007, 44 consecutive patients (mean, 75.2 years) with a Neer Group VI proximal humeral fracture were included. Twenty-two patients treated with a PHILOS(®) plate were compared with 22 patients treated by primary hemiarthroplasty. Both groups were similar in all criteria. At minimum followup of 12 months (mean, 30 months; range, 12-83 months), radiographic control, Constant-Murley score, and SF-36 were performed.
Fourteen patients with complications (63.6%) were counted in the PHILOS(®) plate group, of which 10 (45.4%) needed revision surgery, mostly as a result of avascular necrosis and screw cut-outs. In the primary hemiarthroplasty group, only one patient needed revision surgery (4.5%). Smoking and steroid therapy were substantially associated with complications in the PHILOS(®) plate group. There were no differences between the two groups regarding Constant-Murley or SF-36 scores.
Angular stable open reduction and internal fixation was associated with high complication and revision rates, especially in patients who smoked and those receiving steroid therapy. Primary hemiarthroplasty provides limited function, which had little influence on the quality of life in this elderly collective. There are predictive factors for complications after the treatment of Neer Group VI proximal humeral fractures with the PHILOS(®) plate. Primary hemiarthroplasty remains a good option, especially when treating elderly patients.

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Available from: Christian Spross, Oct 06, 2015
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    • "In addition, the study only addressed four-part fractures. A number of retrospective reviews have compared the two modalities with two reporting no difference [62, 63] and two showing plate fixation to have superior functional outcomes [5, 64] however significant limitations in methodology weaken any definitive conclusions that can be drawn from these. Further adequately powered RCTs comparing plate fixation and hemiarthroplasty are required. "
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    ABSTRACT: Proximal humeral fractures are common and although the majority can be managed non-operatively, the optimal treatment of displaced or complex fractures remains controversial. Non-operative treatment is typically selected for minimally displaced fractures where union rates are high and good or excellent outcomes can be expected in approximately 80% of cases. The aims of surgical fixation are to restore articular surface congruency, alignment and the relationship between the tuberosities and the humeral head. Hemiarthroplasty provides patients with reliable pain relief and its indications include fracture dislocations, humeral head splitting fractures and some three- and four- part fractures. The key areas of surgical technique that influence functional outcome include correctly restoring the humeral height, humeral version and tuberosity position. Function, however, is poor if the tuberosities either fail to unite or mal-unite. The interest in reverse shoulder arthroplasty as an alternative option has therefore recently increased, particularly in older patients with poor bone quality and tuberosity comminution. The evidence supporting this, however, is currently limited to multiple case series with higher level studies currently underway.
    The Open Orthopaedics Journal 06/2014; 8(1):148-56. DOI:10.2174/1874325001408010148
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    ABSTRACT: Background: Locking plates for open reduction-internal fixation (ORIF) of proximal humeral fractures are widely used. We observed an unusually high number of patients with complications referred to our institution. It was the purpose of this study to report these complications, as well as their treatment and outcome. Materials and methods: From 2003 to 2010, all patients treated for complications after ORIF with locking plates for proximal humeral fractures were prospectively collected and retrospectively analyzed. Patients were followed up clinically and radiographically. Results: In total, 121 patients (67 women and 54 men; mean age, 59 years) were referred after primary locking plate ORIF; 80% had a 3- or 4-part fracture. A mean of 3 complications occurred per patient, including malreduction, primary screw cutout, malunion, nonunion, avascular necrosis, and infection. Secondary screw cutout was found in 57% of patients, causing glenoid destruction in 33% of patients. A mean of 1.5 revision surgeries were needed. Hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty improved the mean Constant score (24 to 55 points, P < .05; 29 to 54 points, P = .3; and 25 to 48 points, P < .05, respectively) after a mean of 24 months. In 6 patients, glenoid implantation was no longer possible because of the destruction by perforated head screws. Conclusion: In this negatively selected series, complications resulted in secondary arthroplasties in over 50% of the patients. Shoulder function, though improved, remained substantially restricted even after revision surgery. Glenoid destruction by locking screws was the most devastating and previously almost unseen complication, which limited the options of treatment.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 09/2012; 22(4). DOI:10.1016/j.jse.2012.06.008 · 2.29 Impact Factor
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    ABSTRACT: Objectives: To evaluate the influence of calcium phosphate cement augmentation on failure of locking plate fixation of proximal humeral fracture fixation in a cadaveric fracture model. Methods: A 5-mm wedge osteotomy was created in each of 11 paired fresh-frozen human cadaveric humeri (age > 65 years). Specimens were randomly assigned to receive either locked plate fixation (group 1) or locked plate fixation with cement augmentation (group 2). Constructs were tested for axial stiffness, load to failure, and failure mode using a material testing machine. Results: Cement-augmented specimens resisted higher loads (1936 ± 609 N) in comparison to nonaugmented specimens (1373 ± 590 N) (P = 0.01). In group 1, varus displacement and glenohumeral screw perforation occurred in all cases. Varus displacement occurred in 2 cases in group 2, whereas glenohumeral screw perforation did not occur in any of the cases. Cement augmentation led to a significant increase in axial stiffness (P = 0.04). Conclusions: Calcium phosphate cement-augmented locking plates enhanced fixation stability in proximal humeral fractures and reduced glenohumeral screw perforation in this 2-part cadaveric model. The ultimate advantage of this method remains to be determined in vivo.
    Journal of orthopaedic trauma 10/2012; 27(7). DOI:10.1097/BOT.0b013e318278c595 · 1.80 Impact Factor
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