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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    • "In the case of unacceptable deformity, where greater stability is required to reduce the fracture displacement and to allow early mobilization, surgery is needed. However, at the present time, there is not a standard osteosynthesis technique as data in the literature are inconsistent[4,5].Surgical intervention with open reduction and internal fixation with locking plate is the main recommended option for complex fractures of the proximal humerus, with generally good or satisfactory results in the literature[6,7]. This treatment also presents some disadvantages due to large surgical exposure with risk of iatrogenic avascular necrosis (AVN), axillary nerve damage, risk of secondary dislocation and inaccuracy of execution[8]. "
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    • "This result is comparable to the one prospective study in which the mean Constant score for 4-part fractures was significantly inferior to other types[13]. The results of two studies indicated an advantage in functional outcomes favoring shoulder hemiarthroplasty compared with ORIF with a locking plate in 4-part fracture[24,25]. These results are expected as these fractures are more complex and open reduction and internal fixation is tougher. "

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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.
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