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Complications Associated with Locking Plate of Proximal Humerus Fractures

Authors:
  • Stabiliz Orthopaedics

Abstract and Figures

Proximal humerus fractures constitute a significant percentage of fragility fractures. The growing use of locking plate has helped treat this problem, but at the same time has brought about complications. Past systematic reviews have documented these complications, however a large number of recent studies have been published since, reporting their own complication rates with different techniques. This study reviews the current complications associated with locking plate of proximal humerus fractures as well as methods to reduce them. A systematic review, following the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using PubMed, Scopus, and Cochrane databases, to evaluate locking plate fixation (and complications) of traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of 12-month postoperative followup, articles within the last 5 years, and studies with >10 participants. Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery and Centre for Evidence-Based Medicine guidelines. The initial query identified 51,206 articles from multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal humerus fractures treated with locking plates. Intraarticular screw penetration was the most reported complication (9.5%), followed by varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), nonunion (1.5%), and deep infection (1.4%). Reoperation occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-related complications, which in turn were the main reasons for reoperation. The authors of these studies discussed different techniques that could be used to address these issues. Expanding use of locking plate in the proximal humerus fractures leads to improvements and advancements in surgical technique. Further research is necessary to outline indications to decrease complications, further.
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108 © 2018 Indian Journal of Orthopaedics | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. Venkat Kavuri,
Department of Orthopaedic
Surgery, Drexel University
College of Medicine,
Hahnemann University Hospital,
245 N. 15th St. M.S. 420,
Philadelphia, PA 19103, USA.
E-mail: vckavuri@gmail.com
Access this article online
Website: www.ijoonline.com
DOI:
10.4103/ortho.IJOrtho_243_17
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Abstract
Proximal humerus fractures constitute a signicant percentage of fragility fractures. The growing
use of locking plate has helped treat this problem, but at the same time has brought about
complications. Past systematic reviews have documented these complications, however a large
number of recent studies have been published since, reporting their own complication rates with
different techniques. This study reviews the current complications associated with locking plate
of proximal humerus fractures as well as methods to reduce them. A systematic review, following
the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using
PubMed, Scopus, and Cochrane databases, to evaluate locking plate xation (and complications) of
traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of
12-monthpostoperativefollowup,articleswithinthelast5years,andstudieswith>10participants.
Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible
studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were
included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery
andCentre forEvidence-BasedMedicineguidelines.The initialquery identied51,206articles from
multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting
of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal
humerusfracturestreated with locking plates.Intraarticularscrewpenetration was the mostreported
complication(9.5%),followedby varuscollapse (6.8%),subacromial impingement(5.0%), avascular
necrosis(4.6%),adhesivecapsulitis(4.0%),nonunion(1.5%),anddeepinfection(1.4%).Reoperation
occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-
related complications, which in turn were the main reasons for reoperation. The authors of these
studies discussed different techniques that could be used to address these issues. Expanding use of
lockingplate intheproximal humerusfractures leadstoimprovements andadvancementsinsurgical
technique.Further researchisnecessary tooutlineindications todecreasecomplications, further.
Keywords: Fracture, proximal humerus, locking plate,complications
MeSH terms: Bone plates, humeral fractures, proximal, surgical complications
Complications Associated with Locking Plate of Proximal Humerus
Fractures
Venkat Kavuri,
Blake Bowden,
Neil Kumar,
Doug Cerynik
Department of Orthopaedic
Surgery, Drexel University
College of Medicine,
Hahnemann University Hospital,
Philadelphia, PA, USA
How to cite this article: Kavuri V, Bowden B,
Kumar N, Cerynik D. Complications associated with
locking plate of proximal humerus fractures. Indian J
Orthop 2018;52:108-16.
Introduction
Proximal humerus fractures represent
a steadily growing problem within the
health-care system. Proximal humerus
fractures are the third-most common type
of fragility fracture, accounting for nearly
6% of all adult fractures.1,2 In addition,
as the world’s population has aged, the
incidenceof thisfracturetype hasincreased
as well.3 Surgical intervention for this
fracture type is around 20%, due to the
increase in complications as patients age.3,4
Surgical xation with locking plates is
the most common type of intervention
for displaced proximal humerus fractures,
though other options exist, such as closed
reduction with percutaneous pinning,
hemiarthroplasty,proximal humeral nailing,
andreversetotal shoulderarthroplasty.4,5
Locking plate represents a relatively new
technology that theoretically supports
xation in the setting of osteoporotic
bone.6 Its biomechanical properties made
it promising in the setting of proximal
humerus fractures, where purchase in the
humeral head is difcult to obtain, due
to large variations in bone density and
strength.7 Understandably, complications
were highly variable as locking plates
rst began to be used in the proximal
humerus fractures. The rst systematic
review in this setting noted the importance
of medial calcar support and the need for
more attention to technical aspects of the
procedure.8Sproul etal. performed another
review with a focus on length of followup,
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Review Article
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018 109
tomore accuratelycapturethetimeframenecessaryforthe
development of avascular necrosis (AVN) of the humeral
head.Thestudyconrmed factorsforscrewcutoutand had
similarrates of complications.9
Since the publication of these two reviews, there has been
anincreaseintheliterature,regardinglockingplatexation
for proximal humerus fractures. In addition, studies have
attempted to curtail the complication rates mentioned
earlier with augmentation strategies such as bular strut
allograft, autograft, cancellous chips, suture xation of the
rotatorcuff,anddenedtechnicalsteps,regardingplateand
screw placement. Recent years have shown an increase in
the indications for the use of locking plates, as well as
reverse total shoulder arthroplasty versus hemiarthroplasty
in the setting of proximal humerus fractures.10,11 Given
the relative infancy of locking plate xation at the time of
prior systematic reviews, and the small number of studies
included within each review, a more recent systematic
review of the literature is warranted. This study examines
thecurrentliteraturetoevaluatecomplicationsexperienced
withlockingplateinlightofchangestooperativetechnique
asfamiliaritywith thisimplanthas increased.
Materials and Methods
Following preregistration with PROSPERO
(CRD42015019038), a comprehensive search of the
literature was performed in November 2013 and repeated
in February 2015, to capture recent publications, utilizing
the PubMed, Cochrane, and Scopus databases.12 Database
queries were performed using modiers, limiting results to
publications in the English language of the past 10 years,
in studies involving human subjects. Search terms were
intentionallybroadtoidentifyallrelevantarticles[Table1].
Thestudy designwasconductedstrictlyin accordancewith
the PRISMA guidelines.12 The results were subsequently
ltered for duplicates, and titles and abstracts were
manually screened for relevance and potential adherence
to our inclusion criteria. To be included, eligible studies
must have been conducted in the past 5 years (modier in
initial query was 10 years to ensure broadness of search),
involving 10 or more subjects, adults aged 18 years or
older, and a minimum average followup of 12 months.
International studies with the English translation were
included.Studiesinvolving pathologicfractures,nonhuman
subjects (invitro studies), and cadavers were excluded.
Publications with overlapping or duplicate patient
populationswere excluded.
Next, articles were assigned a quality score using a
previously published quality scoring system, which was
also used by Sproul etal.9,13 The scoring system took into
accountthequalityofthestudydesign,aswellasthequality
of its information. Two reviewers scored the articles and
onlystudies with a minimum score of7/10 were included.
Disagreements were resolved by consensus. Finally, the
studiesweregradedinaccordancewiththeJournalofBone
andJoint SurgeryandCentre forEvidence-BasedMedicine
guidelines, to universally assess the level of evidence of
each study. Statistics were performed by authors with
training in biostatistics. Complication rates were analyzed
in a simple manner, rst divided by the total number of
fractures treated and followed by stratication by level of
evidence. There were no comparative analyses performed
duetothe heterogeneityofeach study.
Results
The initial query conducted through the PubMed, Scopus,
and Cochrane databases identied 51,206 citations. After
removing duplicates and articles with irrelevant titles and
abstracts, a total of 191 full-text articles were assessed
for eligibility. From these 191 articles, 57 articles were
includedto be a part of this systematic review.Theresults
of screening and application of inclusion/exclusion criteria
areoutlined in Figure1.14-70
Therewereseven Level 1, threeLevel2,10Level 3, and
37Level 4studies.Level 1and2 studiesincludedcontrol
groups in regard to surgical approaches, nonoperative
treatment, various treatment modalities, or deferring
operativetechniques.SomeLevel3studieshadabasisfor
comparisonwhenevaluatingdifferent surgicalapproaches
or operative techniques. Finally, Level 4 studies were
caseserieswithout a basis forcomparison.Someof these
series investigated techniques such as strut allografts,
suture xation, bone grafting, and minimally invasive
surgery.
There were a total of 3422 proximal humerus fractures that
were treated with locking plate. Certain studies failed to
mentionorreportthepresenceorabsenceofcomplicationsthat
werespecically beinginvestigated.If thisoccurred,thestudy
was not included in the complication’s analysis. The most
common complication was intraarticular screw penetration
(9.5%), followed by varus collapse (6.8%), subacromial
impingement(5.0%),AVN(4.6%),adhesivecapsulitis (4.0%),
nonunion (1.5%), and deep infection (1.4%). Reoperation
Table 1: Search terms used in the PubMed, Cochrane,
and Scopus databases
Proximalhumerus AND Screw
Plate
Lockingplate
LCP
PHILOS
S3
Fracturexation
Fracturehealing
Openreductioninternalxation
Osteosynthesis
Humerusfracture
Shoulder
LCP=Lockingcompressionplate
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
110 Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018
occurred at a rate of 13.8%. Tables 2-9 display these rates of
complicationsbroken down bylevelsof evidence.
Discussion
Intraarticular screw penetration (9.5%)
Intraarticular screw penetration through the humeral head
has been noted as a problematic complication and may lead
to additional surgery to revise or remove the screw(s). Two
different screw penetrations have been discussed: primary
and secondary. Primary screw penetration refers to the
intraoperative placement of screws into the glenohumeral
joint. Secondary screw penetration refers to the screws that
have violated the articular surface as a result of collapse of
the humeral head due to varus collapse, AVN, or failure of
xation.Reports fromtheearlierliteratureshowtheprevalence
of this complication to range from 0% to 23%.71 Sproul etal.
demonstratedthis complication tobeat a rateof7.5%.9
Level 1
Fjalestad etal. reported that the majority of these
complications occurred in patients with Orthopaedic
TraumaAssociation(OTA)TypeCfractures,withevidence
of AVN.27 Another study noted that attempts to obtain
maximalpurchase intothehumeral headledtohigherrates
of primary screw penetrations. The authors adjusted their
surgical technique by placing screws 2 mm–3 mm away
fromthesubchondralbone,aswasdoneinanotherlevel1
study.48,70 In comparing different plates, Voigt etal. found
that polyaxial locking screws with blunted ends could be
advantageousif screw penetrationwereto occur.65
Level 2
Buecking etal. observed that complications pertaining
to the humeral head were higher in their deltoid-splitting
Table 4: Rate of subacromial impingement
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 1 27 3.7
2 5 270 1.8
312 217 5.5
488 1616 5.5
Total 106 2130 5.0
Table 6: Rate of adhesive capsulitis
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
17 75 9.3
2 Notreported Notreported -
36 150 4.0
436 1015 3.5
Total 49 1240 4.0
Table 2: Rate of intraarticular screw penetration
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 40 192 20.8
2 71 360 19.7
357 639 8.9
4129 1951 6.6
Total 297 3142 9.5
Table 3: Rate of varus collapse
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
111 116 9.5
2423 17.4
3 19 316 6.0
450 788 6.3
Total 84 1243 6.8
Table 7: Rate of nonunion
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 3 272 1.1
2 Notreported Notreported -
36 389 1.5
424 1544 1.6
Total 33 2205 1.5
Table 5: Rate of avascular necrosis
Level Percentage of
occurrences
Percentage of
fractures
Rate
118 283 6.4
24113 3.5
321 489 4.3
488 1956 4.5
Total 131 2841 4.6
51,206 records
11,450 records
PubMed
8,776 records
Cochrane
1,012 records
Scopus
41,418 records
39,756 duplicates
191 full-text articles
11,259 titles/abstracts
excluded
57 articles included
134 articles excluded
Figure 1: Flowchart showing selection of studies
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018 111
approach group, while complications pertaining to the
humeral shaft were higher in their deltopectoral approach
group.19Konrad etal.reportedscrew penetration,notvarus
collapse or loosening, as the most common complication
with locking plate in their large multicenter study of
270patients.34
Level 3
Ina studycomparinglockingplate xationwithcalcium
phosphate cement augmentation versus cancellous bone
chips versus no augmentation, Egol etal. demonstrated
a signicant decrease in intraarticular screw penetration
with calcium phosphate cement augmentation. In
addition, there was no association between the number
of screws in the humeral head and screw penetration.
However, age was associated with screw penetration
as elderly patients sustained this complication more
frequently.26
Level 4
Little etal. described ve incidences of asymptomatic
screw penetration in their series evaluating 72 cases, for
which endosteal augmentation was used. The authors
believed that this intramedullary graft decreased the
working length of the locking screws.38 Ricchetti etal.
reported no cases of screw penetration in their series
of 54 fractures followed for 13 months. The authors
described using screws 5 mm–10 mm away from the
subchondralboneto decrease theriskofscrew perforation
both primarily and secondarily, should collapse occur.
This technique has also been reported in a review article
by Ricchetti et al.52,71 Spross etal. noted that, by placing
screws 4 mm–5 mm away from the subchondral bone,
complications regarding intraarticular screw penetration
decreased signicantly. They also advocated the use of
uoroscopyinthreeplanesinanattempttoavoidmissing
primaryscrew penetrations.62
Varus collapse (6.8%)
Varus collapse represents one of the more important
complications in the setting of locking plate in proximal
humerus fractures. Varus collapse is responsible for
secondarysubacromial impingement and screw penetration
into the articular surface of the glenohumeral joint. Sproul
etal. reported this as the most common complication in
theirreview,at arateof16.3%.9Theauthorsrecommended
thatspecial attention should be paid to the medial column,
which has led some surgeons to place inferomedial
support screws, cement, or graft in hopes of lowering this
complicationrate.
Level 1
In comparing polyaxial versus monoaxial locking screws,
Voigt etal.notedan increaseintherate ofvarusdeformity
in the group treated with monoaxial screws. The authors
felt that polyaxial screws gave more options for screw
placement inferomedially.65 Zhang etal. postulated that
inferomedially placed support screws would resist varus
stresstothehumeral head,thereforemaintainingneckshaft
anglein three- andfour-partfractures.69
Level 2
Evaluating a new carbon ber–reinforced-
polyetheretherketone (CFR-PEEK) locking plate,
Schliemann etal. showed a lower rate of varus deformity
in comparison to the control titanium locking plate. They
believed that this was due to CFR-PEEK being less rigid
andhavinga similarelasticmodulus to bone.58
Level 3
Linetal.reportedlowratesof varus collapse in both their
minimally invasive and deltopectoral approach groups.
However, they attributed a slightly higher rate within the
minimally invasive group due to a false sense of security
with progression through weight-bearing exercises because
offasterwound healingandsmaller scars.37
Level 4
Ricchetti etal. discussed additional contouring of the
locking plate as a method to reduce the incidence of
varus malunion as it aids in obtaining an anatomic
neck–shaft angle. In addition, they placed bone graft for
complicated three- and four-part fractures.52 Kim etal.
performed a study using autologous iliac bone impaction
graft with locking plate of four-part fractures and
reported 0 incidences of varus collapse in 21 cases over
a 27.5-month followup period. The authors believed that
their meticulous attention to restoring the medial calcar,
obtaining sufcient screw purchase in the inferomedial
aspect of the humeral head, and suturing the rotator cuff
to the plate led to such positive results.32 Badman etal.
reported on 81 proximal humerus fractures, a majority of
which were three-part fractures. The authors focused on
Table 8: Rate of deep infection
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 1 124 0.8
2 5 360 1.4
36439 1.4
426 1790 1.5
Total 38 2713 1.4
Table 9: Rate of reoperation
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 34 227 15.0
2 25 113 22.1
362 529 11.7
4228 1658 13.8
Total 349 2527 13.8
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
112 Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018
supplemental suture xation of the rotator cuff in the ve
casesof varuscollapseandalsoused structuralallograftin
thesetting of severeosteopenia.16
Subacromial impingement (5.0%)
Subacromial impingement can be the result of poor
intraoperative plate positioning or the sequelae of humeral
head collapse. Impingement is frequently symptomatic
and may require plate removal. Sproul etal. reported this
complicationat a rateof4.8%.9 Increasedattentiontoplate
placement and preventing varus collapse are the methods
surgeonsare usingtodecreasethis complication.
Level 1
Only one study mentioned a case of subacromial
impingement. Olerud etal. reported one patient in their
treatment group of 27 cases with three-part fractures,
who subsequently required plate removal. The authors
recommended averting humeral head collapse to prevent
thiscomplication.48
Level 2
Konrad etal. attributed their cases of impingement to
placing the plate too superiorly, leading to ve cases in
theirstudy population of270.34
Level 3
Lin etal. attributed their cases of impingement to varus
collapse, while Jung etal. attributed their one case to
intraoperativeerror.31,37Jungetal. describedtheiroperative
positioning of the plate following reduction as caudal to
thesuperior end of the greater tuberosity and lateral tothe
bicipital groove.31 Bachelier etal. instead specied plate
position 1 cm caudal to the superior aspect of the greater
tuberosity.15
Level 4
Sahureportednocase of impingement, taking the shoulder
througharangeofmotion arc before closure of the wound
to detect any symptoms of impingement.55 Osterhoff etal.
describedthemajorityof their 10 cases of impingement to
be strongly associated with medial calcar comminution.49
Ricchetti etal. positioned the locking plate 5 mm–10 mm
lateraltothe bicipital grooveand15mm–20 mm caudalto
thetipof thegreatertuberosity.Twopatients in theirseries
of 54 cases had postoperative subacromial impingement
symptoms.52 Finally, Aggarwal etal. described
provisionallyxing the plate with K-wires and placing the
shoulder through a range of motion arc under uoroscopy.
This technique resulted in ve cases of impingement in
theirseries of 47.14
Avascular necrosis (4.4%)
AVN has been a historic concern with proximal humerus
fractures. Sproul etal. reported this rate to affect 10.8%
of patients.9 This has even led to studies attempting to
discover predictors of necrosis, following a proximal
humerus fracture. Hertel etal. determined that the most
relevant factors included integrity of the medial hinge,
length of the dorsomedial metaphyseal extension, and
different fracture types.72 Furthermore, growing indications
for reverse total shoulder arthroplasty and recent favorable
studies in comparison to hemiarthroplasty may have
articially decreased the rate of AVN currently being
reported.73 In addition, AVN may present later in followup
and inadequate lengths of followup would, in turn, under
report this complication. Recent studies have attempted to
use deltoid-splitting or minimally invasive approaches with
thebeliefthat less soft tissue disruption in proximity to the
humeral head would preserve its blood supply. Finally,
thereis growingbeliefthatasymptomatic casesofAVN can
potentiallyover-report thisseriouscomplication.
Level 1
Comparing the minimally invasive approach to the
deltopectoral approach, Liu etal. reported one case of
AVNinthelattergroupandzero inthe former.Theauthors
believed that the minimally invasive approach decreased
softtissuestrippingand preserved the bloodsupplyaround
the proximal humerus.39 Zhang etal. reported only one
case ofAVNin their study that focused on medial support
screws using a deltopectoral approach. In their opinion,
preventingmedialcollapsealso aided in preventingAVN.69
Interestingly,the ndings fromFjalestadetal.showedthat
nonoperatively treated patients had a higher rate of AVN
thanthoseintheoperativegroup.Allpatientshaddisplaced
three-andfour-partfractures.27
Level 2
Bueckingetal.reported no case ofAVNand nodifference
between deltoid-splitting and deltopectoral approaches.
Followup,however,wasonlyfor1year.19Schliemannetal.
reportedalower incidence ofAVN in patients treated with
theirCFR-PEEKimplantcomparedtoconventionallocking
plate.Their followupwasfora minimumof2years.58
Level 3
Martetschlager etal. reported higher rates of AVN in
patients treated with a deltopectoral approach compared
to a minimally invasive deltoid-splitting approach. With a
mean followup of nearly 4 years, AVN was diagnosed in
six of 33 patients in the deltopectoral approach group and
oneof37patients in the deltoid-splittingapproachgroup.41
Wu etal. reported similar ndings over a mean followup
of2.5yearsincomparinga minimallyinvasive approachto
adeltopectoral approach.67
Level 4
Using a minimally invasive plating technique and a mean
followup of nearly 3 years, Chen etal. reported only one
case of AVN in their series of 64 cases.21 Little etal.
reported low rates of AVN as well by using a deltoid
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018 113
splitting approach and a medial strut allograft.38 On the
otherhand,Sprossetal.reported 20 cases ofAVN in their
large case series of 294 followed for 1 year. The patients
were treated using a deltopectoral approach. The authors
determined,however,thatfracture type inuenced whether
AVN occurred or not, with fracture dislocations having the
highestrate.62
Reoperations (13.8%)
Reoperations are a very important measure of how
successful the index operation was and also highlight the
most signicant complications. Reoperations also highlight
possible improvements in surgical decision-making or
technique to avoid certain complications. Even in regard
toAVN,more meticulous soft tissuemanagement,attempts
at minimally invasive techniques, and consideration of
arthroplasty as primary surgery have led to a decrease
in reoperation. It is also important to make a distinction
between“planned”versus“unplanned”operationsasmany
patients do request to have hardware removed. Hardware
removal has been associated with a very low complication
rate and high patient satisfaction as indicated in a recent
case series.74 This should be differentiated from the need
toundergoanarthroplasty procedure due to failed primary
openreductionand internalxation(ORIF).
Level 1
Cai etal. reoperated on three of 12 patients following
lockingplate.Thepatientsoriginallyhadfour-partfractures
and reoperations were during the 2nd year of followup.
Plates were removed for xation failure and revision
internal xation for nonunion.20 Zhu etal. performed ve
screw revisions due to primary screw penetration.70 Voigt
etal. attributed the majority of reoperations in their study
duetosecondary displacementofthe greater tuberosity.65
Level 2
Buecking etal. reported a large number of reoperations:
three screw revisions, 18 plate removals, four revision
ORIF, and seven arthroplasties in their study population of
90.19 Seventeen of the plate removals were at the request
of the patient and the rest were due to screw perforation,
implant loosening, or infection. Schliemann etal.
performed seven plate removals with arthrolysis in two of
thosecases.58
Level 3
Kralinger etal. reported mechanical failure as a strong
predictorofreoperationintheirstudyconsistingofmajority
three- and four-part fractures. Two revision arthroplasties,
six capsular releases, six revisions of internal xation,
14 plate removals, and one hematoma evacuation were
performed.35 Sanders etal. discussed screw revisions and
plateremovals secondarytointraarticularscrewpenetration
and impingement, respectively,as a major reason for their
50%reoperation rate.56
Level 4
Ockert etal. noted an unplanned reoperation rate of 14%
andaplannedreoperationrate(duetoimpingement,patient
request, or range of motion decit) of 40% in its series of
43 patients followed for 10 years.46 Kim etal. reported
2 implant removals for cultural reasons in their case
seriesof 21 four-part fractures followed for 27.5months.32
Finally,Schliemann etal. reported impingement and screw
penetration as the primary reason their revision rate was
closeto 30%.57
The data presented in this systematic review not only
support data from past reviews but also present potential
solutions proposed by investigators, in the hopes of
decreasing the complication rate associated with locking
plate of proximal humerus fractures. Recent reviews have
emphasizedtheimportanceofAVNandfracturedislocation
patterns negatively impacting outcome. Complex,
intraarticularfracturepatternshavehighcomplicationrates
when treated with locking plate. Brorson etal. also noted
that the methodological quality of studies is lacking.75
Tepass etal. noted that three- and four-part fractures
actually had better outcomes when treated with head
preservingsurgery comparedtoa hemiarthroplastyandthat
there were an increase in the number of complications as
the fracture complexity increased.76 Finally, in a review
specically looking at referrals for complications, Jost
etal. discussed the importance of making the primary
surgery the denitive surgery. A majority of the patients
received arthroplasty as a revision surgery, secondary to
complicationsfromlockingplate. Inthesepatients,primary
reduction was not achieved, indicating that the more
complexfracturepatternsmay not necessarily be amenable
tolocking plate.77
None of the articles presented in this review were in
the most recent comprehensive systematic review, as
Sproul etal. completed their literature search in 2009.
In addition, none of the articles from the previous
systematicreviewsarein thisreviewasweonlyincluded
the most recent articles. We repeated our queries to
capture the most recent literature and data, noting
that there were quite a few articles we would not have
been able to include. More experience with locking
plate in treating proximal humerus fractures and the
application of newer techniques has denitely adjusted
complicationrates. Moreover,the complicationratesmay
not have been entirely accurate in the previous reviews
as they were analyzing a smaller number of total cases.
Thus, one of the aims of this review was to encompass
asmanyrecentarticleswithoutsacricingquality,which
we accomplished by including only high scoring articles
intothisstudy.
It is also worthwhile to discuss the fact that there is
a large amount of literature describing nonoperative
treatment of proximal humerus fractures. Concerning
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
114 Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018
the number of complications as well as costs associated
with surgical treatment, there have also been studies
comparing operative versus nonoperative treatment of
these fractures. Handoll etal. found in their Proximal
Fracture of the Humerus: Evaluation by Randomization
trial that surgical treatment does not result in
improved outcomes in most patients and that it is not
cost effective.78 This lends support to the argument that
every fracture should be treated on a case-by-case basis.
Theosteoporoticnature of someofthesefractures leaves
it incredibly difcult to treat, and though locking plate
hasbeenpromising intheory,noteveryplateis the same
and cannot replicate force distributions of the proximal
humerus. The most used plate seemed to be the Synthes
PHILOS plate; however, not every article in our review
reported which plate they used. The design of the plate
cannot prevent varus collapse and subsequent cutout of
the screws. Biomechanical studies have shown this and
the importance of a medial buttress to prevent those
complications.79
There are a number of limitations to this review. First,
minimumfollowupwassetto12months, which may have
underestimated the incidence and prevalence of AVN. Not
every article commented on every complication analyzed
inthisreport.This could haveledtoeitherunder-reporting
or over reporting of results. Next, the heterogeneity of the
articles, whether it was based on level of evidence, type
offracture,approach,or specic technique used, could not
be fully accounted for. In addition, we did not perform a
metaanalysis of the complication rate. Our aim was to
provide a broad overview of complications with proposed
methods to decrease complication rate. A meta-analysis
wasnot ourgoalas wecannotequallycompareeachstudy,
such as comparing a three part fracture with a four-part
fracture. An attempt was made to highlight the most
important conclusions from each article. Finally, giving
moreweighttoarticleswith higher levels of evidence may
haveskewedthe resultsaswell.
Conclusion
The points of consideration from this review, in regard to
the major complications associated with locking plate in
proximalhumerus fractures, areasfollows:
Screw penetration
Greater care with uoroscopy, use of at least two
perpendicular planes to conrm screw is not within the
glenohumeral joint. Placement of screws that are too short
ofsubchondralbone shouldbeavoided.
Varus collapse
Ensure the medial column is intact (medial hinge).
Considerationoftheuseofstrutallograft,bonegraft,suture
augmentation,andplatecontouring.Considerplacementof
inferomedialsupport screws.
Subacromial impingement
Ensuretheplatedoesnotsittooproximally,AVN,Consider
fracture type to stratify risk of AVN, Careful soft-tissue
dissection,Considerminimally invasivetechniques.
Financial support and sponsorship
Nil.
Conicts of interest
Thereareno conictsofinterest.
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... Proximal humerus fractures represent a steadily growing problem within the health-care system. These fractures are the third-most common type of fragility fracture, accounting for nearly 6% of all adult fractures [2] and make up 80% of all humerus fractures [1] . Moreover, as the world's population has aged, the incidence of this fracture type has increased as well [2] . ...
... These fractures are the third-most common type of fragility fracture, accounting for nearly 6% of all adult fractures [2] and make up 80% of all humerus fractures [1] . Moreover, as the world's population has aged, the incidence of this fracture type has increased as well [2] . Proximal humerus fractures have been a challenge to achieve stable fixation [3] . ...
... However, it carries several risks and complications. According to a meta-analysis of 3422 cases, complications occurred at the following rates: intra-articular screw penetration (9.5%), varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), non-union (1.5%), and deep infection (1.4%) [34]. These complications tended to increase with the patient's age and the complexity of the fracture [34][35][36][37][38]. Additionally, the presence of osteoporosis further exacerbates these risks. ...
... According to a meta-analysis of 3422 cases, complications occurred at the following rates: intra-articular screw penetration (9.5%), varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), non-union (1.5%), and deep infection (1.4%) [34]. These complications tended to increase with the patient's age and the complexity of the fracture [34][35][36][37][38]. Additionally, the presence of osteoporosis further exacerbates these risks. ...
Article
Full-text available
Proximal humerus fractures (PHFs) are among the most common upper-extremity fractures, with a rising incidence linked to the growing elderly population. Treatment options include non-surgical and surgical methods, but the best approach for geriatric PHFs remains debated. Patient selection for treatment must consider clinical and functional outcomes and the potential complications of surgery. Osteoporosis, a key factor in elderly PHFs, meaning those in patients over 65 years old, often results from low-energy trauma and necessitates treatments that enhance bone healing. Bone cement, such as calcium phosphate, is widely used to improve fracture stability and healing. However, the benefits of surgical fixation with bone cement augmentation (BCA) for elderly PHF patients remain controversial. Hence, in this article, we searched databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science to analyze the evidence on locking plate fixation (LPF) with BCA for proximal humeral fractures. We aim to provide readers with updates concerning the above issues.
... 11,12 as in other types of injuries, [33][34][35][36][37] proper patient selection, surgical technique, and post-operative rehabilitation are critical across all treatment modalities to minimize complications and improve outcomes. 38,39 Conclusions high-energy PhFs represent a challenging clinical scenario requiring a comprehensive understanding of injury mechanisms, classification systems, and treatment modalities. Ongoing research into optimal management strategies is essential to improve functional outcomes and minimize complications in affected patients. ...
... Previous studies have found that the incidence of complications after proximal humerus fractures repaired with a lateral locking plate is approximately 16-64% when the medial column of the proximal humerus is involved [12]. There are often bony structural defects in the medial column after reduction during surgery [13]. ...
Article
Full-text available
Background The lateral locking plate for the proximal humerus is currently the most commonly used surgical procedure for the treatment of elderly proximal humeral comminuted fractures. Previous studies have found that the rate of postoperative complications in patients of proximal humerus fractures with medial column involvement is relatively high. Through biomechanical methods, this study aims to investigate the effectiveness of the conventional lateral locking plate fixation along with the addition of the metacarpal supporting plate on the medial column in the treatment for proximal humeral fractures involving the medial column. The goal is to reduce the rate of postoperative internal fixation failure in patients with medial column injury. Methods Thirty artificial synthetic humerus models are used as experimental samples. A proximal humerus fracture model with medial column injury was created, and then divided into two groups. Group A was fixed with a proximal humerus lateral locking plate (single-plate group). Group B was fixed with a proximal humerus lateral locking plate and a metacarpal supporting plate on the medial column (double-plate group). The failure displacement, stiffness, and strength of the repaired proximal humerus fractures with two different methods were tested under compression at posterior extension of 15°, forward flexion of 15°, and vertical direction. Results There was no statistical significance in the comparison of the failure displacement of repaired proximal humeral fractures between the two groups under compression at posterior extension of 15° and forward flexion of 15° (P > 0.05). However, the failure displacement of the fracture was longer in single-plate group than in double-plate group under compression at vertical direction (P < 0.05). The double-plate group was better in terms of biomechanical stiffness and strength compared to the single-plate group at all three testing angles (P < 0.05). Conclusions For patients whose proximal humeral fractures involve the medial column, the addition of a support plate on the medial side of the humerus is recommended along with the lateral locking plate. The double-plate strategy can increase the stability of the medial column of the proximal humerus, and enhance the overall biomechanical property of the repaired proximal humerus.
... Несмотря на это, в настоящее время не существует «золотого стандарта» хирургического лечения данных переломов [14]. Во всем мире продолжаются работы по изобретению новых видов имплантов, различных способов для улучшения результатов хирургической реабилитации переломов проксимального отдела плечевой кости [15]. ...
Article
Введение. Переломы проксимальной части плечевой кости составляют 5 - 10% от всех переломов опорно-двигательной системы. В мировой литературе описаны множество методов хирургического лечения вышеуказанных переломов, но до сих пор не существует общепринятого стандарта. В связи с чем все еще продолжаются работы по изобретению новых видов имплантов, различных хирургических методов для улучшения результатов хирургической реабилитации переломов проксимального отдела плечевой кости. Цель исследования. Разработать новое устройство для стабильно-функционального остеосинтеза переломов проксимального отдела плечевой кости. Материалы и методы. Было изобретено новое устройство для остеосинтеза переломов проксимального отдела плечевой кости. Для проверки стабильности остеосинтеза перелома проксимального отдела плечевой кости разработанным устройством было проведено биомеханическое исследование в системе «кость – фиксатор - кость». Всего было использовано 4 штуки моделей плечевой кости Humerus, 4th Gen., фирмы «Sawbones». Был смоделирован перелом хирургической шейки и проведены испытания на сжимание со скоростью 5 мм/мин и на скручивание со скоростью 50/мин в режиме статической нагрузки. Результаты. При исследовании двух моделей плечевой кости в системе «кость-фиксатор-кость» на сжимание, средняя величина предельной нагрузки составила 1105,35 Ньютона, средняя величина смещения отломков при вышеуказанной нагрузке составило 1,61 мм. При исследовании двух моделей плечевой кости в системе «кость-фиксатор-кость» на скручивание, средняя величина предельной нагрузки составила 16.22 Нм, а средний угол смещения отломков при вышеуказанной нагрузке составил 48.970. Выводы. Проведенное биомеханическое исследование доказало стабильность остеосинтеза перелома проксимального отдела плечевой кости разработанным устройством. В исследование не было включено контрольной группы, в связи с чем в дальнейшем необходимо провести компьютерное моделирование методом конечных элементов с включением контрольной группы со стандартной блокируемой пластиной. Introduction.Proximal humerus fractures account for 5–10% of all fractures of the musculoskeletal system. Many methods of surgical treatment of the proximal humerus fractures are described in the world literature, but there is still no generally accepted standard. According to the above information, the invention of new types of implants and various surgical methods to improve the results of proximal humerus fractures surgery is still continuous. Aim. To develop a new device for stable and functional osteosynthesis of the proximal humerus fractures. Materials and methods. A new device for osteosynthesis of proximal humerus fractures was invented. The biomechanical study was carried out in the “bone-fixator-bone” system, to check the stability of osteosynthesis of the proximal humerus fracture by the developed device. A total of 4 Humerus humerus models, 4th Gen., from “Sawbones”, were used. A surgical neck fracture was made and compression tests were performed at a speed of 5 mm/min and torsion tests at a speed of 50/min in static load mode. Results. When studying two models of the humerus in the “bone-fixator-bone” system for compression, the average maximum load was 1105.35 Newton, the average displacement of fragments under the above load was 1.61 mm. When studying two models of the humerus in the “bone-fixator-bone” system for torsion, the average maximum load was 16.22 Nm, and the average angle of displacement of the fragments at the above load was 48.970. Conclusion.The biomechanical study proved the stability of osteosynthesis of the proximal humerus fracture using the developed device. The study did not include a control group, and therefore further finite element computer simulations should be performed to include a control group with a standard locking plate. Өзектілігі. Тоқпан жіліктің проксимальды бөлігінің сынықтары тірек-қимыл жүйесінің барлық сынықтарынын 5-10% құрайды. Әлемдік әдебиеттерде жоғарыда аталған сынықтарды хирургиялық емдеудің көптеген әдістері сипатталған, бірақ әлі күнге дейін қабылданған стандарт жоқ. Осыған байланысты тоқпан жіліктің проксимальды бөлігі сынықтарынын хирургиялық оңалту нәтижелерін жақсарту үшін импланттардың жаңа түрлерін, әртүрлі хирургиялық әдістерді ойлап табу жұмыстары әлі де жалғасуда. Зерттеудің мақсаты. Тоқпан жіліктің проксимальды бөлігі сынықтарының тұрақты-функционалды остеосинтезіне арналған жаңа құрылғы ойлап табу. Материалдар мен әдістер. Тоқпан жіліктің проксимальды бөлігі сынықтарының отеосинтезіне арналған жаңа құрылғы жасалынды. Тоқпан жіліктің проксимальды бөлігі сынықтарының әзірленген құрылғымен остеосинтезінің тұрақтылығын тексеру үшін «сүйек – фиксатор – сүйек» жүйесінде биомеханикалық зерттеу жүргізілді. «Sawbones» фирмасында жасалған Humerus, 4th Gen. тоқпан жілік модельдерінің барлығы 4 данасы қолданылды. Хирургиялық мойынының сынығы модельденіп, статикалық жүктеме режимінде 5 мм/мин қысу және 50/мин бұралу сынақтары жүргізілді. Нәтижелері. "Сүйек-фиксатор-сүйек" жүйесіндегі иық сүйегінің екі моделін қысу режимінде зерттеген кезде, шекті жүктеменің орташа мәні 1105,35 Ньютонды құрады, жоғарыда көрсетілген жүктеме кезінде сынық бөліктерінің жылжуының орташа мәні 1,61 мм құрады. "Сүйек-фиксатор-сүйек" жүйесіндегі иық сүйегінің екі моделін бұралу режимінде зерттеген кезде шекті жүктеменің орташа шамасы 16.22 Нм, ал жоғарыда көрсетілген жүктеме кезінде сынық бөліктерінің жылжуының орташа бұрышы 48.970 құрады. Тұжырым. Жүргізілген биомеханикалық зерттеу тоқпан жіліктің проксимальды бөлігі сынықтарын әзірленген құрылғымен остеосинтезі тұрақты екенін дәлелдеді. Зерттеуге бақылау тобы енгізілмеген, осыған байланысты болашақта стандартты құлыптама пластина қолданылған бақылау тобын қоса отырып, ақырлы элементтер әдісімен компьютерлік модельдеу жүргізу қажет.
... [14,17] According to a meta-analysis published in 2018, the most common complication is intra-articular screw penetration, occurring at a rate of 9.6%. [18] However, in our study, we found that none of the patients experienced screw penetration during early or late follow-ups, despite 53% having Neer type 4 fractures and approximately 93% showing impaired medial hinge integrity. A 2012 study examining the outcomes of locking plate and fibular allograft application in 17 patients with three-or four-part proximal humerus fractures reported no occurrences of screw penetration during an average follow-up period of 13 months. ...
Article
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Background: Open reduction and internal fixation (ORIF) using locking plates is a widely adopted treatment for displaced proximal humerus fractures. Various augmentation techniques have been developed to enhance the stability of plate fixation. Among these, iliac bone autograft is notable for its advantages over allografts, such as ready availability and the elimination of costs and risks associated with disease transmission. Despite its potential benefits, data on the outcomes of iliac bone autograft augmentation (IBAA) are still limited. This study aims to present the mid- to long-term results of treating proximal humerus fractures with ORIF using locking plates and IBAA. Methods: The study included 15 patients treated with ORIF and IBAA. We classified fracture patterns using the Neer classification and estimated local bone density via the deltoid tuberosity index. We measured the neck shaft angle (NSA) and humeral head height (HHH) on both immediate postoperative and most recent X-ray images to assess the maintenance of reduction. Clinical outcomes were evaluated using the DASH (Disabilities of the Arm, Shoulder, and Hand) and Constant scores. Results: The average follow-up duration was 59.56 months, ranging from 24 to 93 months. A majority of fractures were classified as four-part (53%). The average immediate and late postoperative NSAs were 132.6±8.19 and 131.6±7.32 degrees, respectively. The average HHH on the immediate postoperative and latest follow-up images were 16.46±6.07 and 15.10±5.34, respectively. None of the patients exhibited any radiological signs of avascular necrosis or loss of reduction at the latest follow-up. The mean postoperative Constant and DASH scores at the latest follow-up were 79.6 and 11.5, respectively. Conclusion: Our findings suggest that ORIF with IBAA is an effective method for managing three- or four-part proximal humerus fractures, yielding excellent outcomes.
... Proximal humerus locked plating is the most used construct for surgical treatment of proximal humerus fractures [11]. Advantages of locked plating include greater stability and earlier mobilization [12]. ...
Article
Full-text available
Background Post-operative non-compliance is a risk factor for fracture fixation failure and presents a challenge for revision surgery planning. We present a patient who underwent revision surgery for a proximal humerus fracture with lateral locked plating augmented with a UV light activated intramedullary implant. Case A 45-year-old woman with a history of alcoholism presented with a proximal humerus fracture. After undergoing open reduction internal fixation with a lateral locking plate, the patient suffered a fall secondary to delirium tremens. New radiographs demonstrated displacement of the fracture with failure of screws. Revision surgery consisting of removal of the initial construct as well as open reduction internal fixation via lateral locking plate, augmented with a UV-activated intramedullary cement implant, was performed. Conclusion This is the first case report describing the use of a UV-activated intramedullary cement implant to augment the use of lateral locked plating for proximal humerus fractures. This case illustrates the successful management using UV-activated intramedullary cement to augment fixation, specifically in a patient with risk factors and post-operative non-compliance that predispose to fixation failure.
... Reoperation occurred at a rate of 13.8%. These data are according to Venkat Kavuri et al. [18] study of the complication of plate fixation. However, in our OG only one patient returned to operating room within first year post treatment. ...
Article
Full-text available
Proximal humerus fractures account for about 5% of fragility fractures. These involve a significant burden of disability and a reduced quality of life. This study aims to compare functional results and surgical outcomes (closed reduction and internal fixation with the internal closure system of the proximal humerus) and the conservative management of proximal humerus fractures by 2-, 3-, 4-parts, in patients older than 55 years. Between January 2017 and April 2019, 65 patients with 2, 3 or 4-part fractures were retrospectively analyzed: 29 patients (5 males and 24 females) with an average age of 70.8 ± 9.9 years treated non-surgically (conservative group (CG)) and 36 patients (11 males and 25 females) with an average age of 66.2 ± 7.1 years treated surgically with plate fixation (operating group (OG)). Using different evaluation scores, we compared the OG and the CG. Through the DASH score we have seen how at 12 months there is a satisfactory result in patients with conservative treatment (p = 0.0019). Constant-Murley scale shows no difference between the two treatments (p = 0.2300). BARTHEL scale and SST score did not give statistically satisfactory results. Also, after one year of follow-up, patients treated with conservative therapy had a higher improvement in their Range of Motion (ROM) values than patients treated with surgical treatment. The results in terms of pain in NPRS at 3, 6, 12 months are better for conservative groups (p = 0,0000). Our findings suggest that conservative treatment in proximal humeral fractures, particularly in multi-fragmented fractures in patients over 55 years of age, designs an excellent alternative to the surgical option.
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Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck. To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults. A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years. Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation. Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck. The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups. The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected. The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses. Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care. Current Controlled Trials ISRCTN50850043. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.
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Background Despite the wide application of open reduction and internal fixation with locking plates for the treatment of proximal humeral fractures, the surgical invasive approach remains controversial. This study aimed to evaluate the pros and cons of the minimally invasive lateral approach for the treatment of proximal humeral fracture (PHF) in comparison with the deltopectoral approach. Material/Methods All patients who sustained a PHF and received open reduction and internal fixation (ORIF) surgery with locking plate through either minimally invasive subacromial approach or conventional deltopectoral approach between January 2008 and February 2012 were retrospectively analyzed. Patients were divided into the conventional group and min-group according to the surgical incision. Surgery-related information, postoperative radiography, complications, and shoulder functional measurement scores in a 2-year follow-up were collected and evaluated. Results Ninety-one patients meeting the inclusion criteria were included in this study. We observed a significant difference in both surgery time (81.8±18.3 vs. 91.0±18.4) (p=0.021) and blood loss (172±54.2 vs. 205±73.6) (p=0.016) between the min-group and conventional group. Compared to the conventional group, the min-group had significantly better Constant-Murley score and DASH score at early follow-up (p<0.05) and higher patients satisfaction rate (8.1±1.1 vs. 7.6±1.2) (p= 0.019). The multiple linear regression analysis indicated that age, PHF types, surgical groups, surgery time, and blood loss have significant effect on the activity of affected shoulder in both abduction and forward flexion (p<0.05) except for gender factor. While larger range of movement of the affected shoulder, mainly in the 2-part and 3-part fractures, was observed in the min-group, the conventional group obtained better movement in the 4-part fractures. Conclusions The minimally invasive lateral approach is the optimal alternative for the treatment of Neer’s type 2 and 3 proximal humerus fractures.
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Background: Displaced proximal humeral fractures, which used to be treated conservatively in the past, often had compromised functional results. With the advancement of technology, these fractures are now more often managed operatively, fulfilling the demands of an active and productive life style by the patients. The aim of this study was to assess the functional outcome of management of proximal humeral fractures with Philos (Synthes; Johnson and Johnson, West Chester, Pennsylvania, USA) plate fixation. Methods: In this prospective study, 40 patients aged 18–80 years (mean age 52.4 years) with fractures of the proximal humerus, including two-, three-, and four-part fractures, were treated by open reduction internal fixation with Philos plating. Patients were functionally evaluated based on subjective (35 points) and objective (65 points) parameters as per the constant scoring system. Results: All these operated patients were followed up for 18–36 months (average 27.3 months). Functional outcome based on the constant scoring system showed excellent results in 20 (50%), good in eight (20%), and moderate in eight (20%) patients. Four (10%) patients had poor functional results. Out of six cases of four-part fracture dislocations, avascular necrosis of the humeral head was observed in two patients. One of these two patients had avascular necrosis of the head along with nonunion of the fragment to the shaft. Conclusion: Philos plate fixation for proximal humeral fractures provides good stable fixation with good functional outcome and minimal complications.
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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. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
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The use of reverse shoulder arthroplasty is becoming increasingly popular for the treatment of complex three- and four-part proximal humerus fractures in the elderly compared with the often unpredictable and poor outcomes provided by open reduction and internal fixation and by hemiarthroplasty. Inferior results with plate osteosynthesis are often a result of complications of humeral head osteonecrosis, loss of fixation, and screw penetration through the humeral head, whereas major concerns with hemiarthroplasty are tuberosity resorption, malunion, and nonunion resulting in pseudoparalysis. Comparative studies support the use of reverse shoulder arthroplasty in elderly patients with complex proximal humerus fractures because the functional outcomes and relief of pain are reliably improved. Repair and union of the greater tuberosity fragment during reverse shoulder arthroplasty demonstrates improved external rotation, clinical outcomes, and patient satisfaction compared with outcomes after tuberosity resection, nonunion, or resorption. Satisfactory results can be obtained with careful preoperative planning and attention to technical details. Copyright 2015 by the American Academy of Orthopaedic Surgeons.