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Akgün D, Paksoy A, Imiolczyk JP, Bahlawane S, Gebauer H, Dey Hazra RO, Stöckle U, Braun KF, Moroder P. Intraoperative Doppler flowmetry evaluation of humeral head perfusion after proximal humerus fracture. JSES Int 2024; 8:990-994. [PMID: 39280151 PMCID: PMC11401537 DOI: 10.1016/j.jseint.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
Abstract
Background Understanding vascularity and assessing the risk of post-traumatic avascular necrosis are crucial for predicting outcomes and identifying optimal treatment options in proximal humerus fractures (PHFs). Until now, Hertel et al have been the only researchers to evaluate the intraoperative perfusion of the humeral head after fracture using Doppler flowmetry in a central single drill hole within the head. This pilot study aims to standardize the evaluation of intraoperative perfusion measurements in different areas of the humeral head in patients with PHF. Methods In this prospective pilot study, intraoperative semiquantitative Doppler perfusion measurements were conducted during plate osteosynthesis for PHF treatment in our institution between July 2021 and May 2022. The fracture morphology was classified radiologically according to Resch's criteria. Quality of reduction was determined postoperatively to be either anatomical, minor malreduced, or major malreduced according to Peters et al in conventional and computed tomography examinations. Medial hinge integrity and medial metaphyseal extension were assessed radiographically according to Hertel et al. Intraoperatively, after drilling screw holes through the plate, a Doppler probe was inserted through all nine drill holes on the humeral head and at least one on the humeral shaft to successively measure the presence of a pulse to indicate if perfusion is present. Results A total of ten patients (mean age 59 years, range, 36-83) with a humeral head fracture (2 × 2GL, 3 × 3G, 2 × 4G, 2 × 4GL, 1 × 5aG according to Resch) were included. Nine of the ten patients showed a pulse signal on the humeral shaft. Overall, pulse-synchronous perfusion was detected using Doppler sonography in at least one hole in the humeral head of all patients. In patients with an intact medial hinge (N = 6), pulse-synchronous perfusion could be measured in almost twice as many humeral head holes on average (5.7 vs. 3.0 drill holes) compared to patients with a dislocated medial hinge (N = 4). In patients with metaphyseal extension (N = 3), pulse-synchronous perfusion was measured in an average of 6.7 humeral head holes compared to 3.7 holes in patients without metaphyseal extension (N = 7). Conclusion Semiquantitative, intraoperative Doppler flowmetry offers a noninvasive and rapid assessment of humeral perfusion which allows an understanding of humeral head perfusion, when used in a standardized fashion to measure flow in different areas of the humeral head.
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Affiliation(s)
- Doruk Akgün
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Alp Paksoy
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Soraya Bahlawane
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Henry Gebauer
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Ulrich Stöckle
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Philipp Moroder
- Orthopaedic clinic, shoulder and elbow surgery, Schulthess Klinik, Zurich, Switzerland
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Delbast L, Koneazny C, Baroan C, Niéto H. Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus. Injury 2024; 55 Suppl 1:111345. [PMID: 39069340 DOI: 10.1016/j.injury.2024.111345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 01/14/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality. METHODS Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs. RESULTS All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side. DISCUSSION A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head. CONCLUSION Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.
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Affiliation(s)
- Laurent Delbast
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France.
| | - Christopher Koneazny
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
| | - Célestin Baroan
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
| | - Hervé Niéto
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
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Levy HA, Szeto S, O Starks A, Davis DE. Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review. Shoulder Elbow 2023; 15:6-18. [PMID: 37974637 PMCID: PMC10649504 DOI: 10.1177/17585732221099200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2023]
Abstract
Background Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA. Methods An electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA). Results Fifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, p = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, p = 0.026). Conclusions RSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stanley Szeto
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexandria O Starks
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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Wang M, Wang X, Cai P, Guo S, Fu B. Locking plate fixation versus intramedullary nail fixation for the treatment of multifragmentary proximal humerus fractures (OTA/AO type 11C): a preliminary comparison of clinical efficacy. BMC Musculoskelet Disord 2023; 24:461. [PMID: 37277746 DOI: 10.1186/s12891-023-06567-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/23/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND This study aimed to compare the clinical efficacy of locking plate and intramedullary nail fixations in the treatment of patients with OTA/AO type 11C proximal humerus fractures. METHODS We retrospectively analyzed the data of patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures who underwent surgery at our institution from June 2012 to June 2017. Perioperative indicators, postoperative morphological parameters of the proximal humerus, and Constant-Murley scores were evaluated and compared. RESULTS Sixty-eight patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures were enrolled in this study. Overall, 35 patients underwent open reduction and plate screw internal fixation, and 33 patients underwent limited open reduction and locking of the proximal humerus with intramedullary nail internal fixation. The total cohort had a mean follow-up duration of 17.8 months. The mean operation time of the locking plate group was significantly longer than that of the intramedullary nail group (P < 0.05), while the mean bleeding volume was significantly higher in the locking plate group than that in the intramedullary nail group (P < 0.05). The initial neck-shaft angles, final neck-shaft angles, forward flexion ranges, or Constant-Murley scores did not show significant differences between the two groups (P > 0.05). Complications, including screw penetrations, acromion impingement syndrome, infection, and aseptic necrosis of the humeral head, occurred in 8 patients (8/35, 22.8%) in the locking plate group and 5 patients in the intramedullary nail group (5/33, 15.1%; including malunion and acromion impingement syndrome), with no significant difference between the groups (P > 0.05). CONCLUSIONS Similar satisfactory functional results can be achieved with locking plates and intramedullary nailing for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures, with no significant difference in the number of complications between these two techniques. However, intramedullary nailing has advantages over locking plates for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures in terms of operation time and bleeding volume.
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Affiliation(s)
- Minghui Wang
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Xiuhui Wang
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Pan Cai
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Shengyang Guo
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China
| | - Beigang Fu
- Department of Orthopedics, Shanghai University of Medicine & Health Sciences Affiliated to Zhoupu Hospital, Shanghai, 201318, China.
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Baldairon F, Antoni M, Le Thai V, Clavert P. Is early mobilization a viable option after intramedullary nailing of 4-parts proximal humerus fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03478-1. [PMID: 36715762 DOI: 10.1007/s00590-023-03478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Abstract
INTRODUCTION After centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate. MATERIALS AND METHODS All patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B. RESULTS The average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149° (80°-180°) in group A versus 134 (60°-180°) in group B (p = 0.099); active external rotation 145° (15°-70°) in group A versus 42° (15-70°) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis. CONCLUSION Early mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant. EVIDENCE LEVEL IV, retrospective study.
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Affiliation(s)
- Florent Baldairon
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Maxime Antoni
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France.
| | - Vinh Le Thai
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Philippe Clavert
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France
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Fidanza A, Rossi C, Iarussi S, Necozione S, Indelli PF, Calvisi V. Proximal humeral fractures treated with a low-profile plate with enhanced fixation properties. J Orthop Sci 2022; 27:1298-1303. [PMID: 34625328 DOI: 10.1016/j.jos.2021.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/30/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our purpose was to evaluate the clinical and radiographic outcomes of proximal humeral fractures treated with a new generation plating system and compare results with a meta-analysis of recent literature. METHODS Between 2014 and 2017, 93 patients (18 males, 75 females) with proximal humerus fractures were treated with open reduction and internal fixation (ORIF) using a Pantera® Plate. These low-profile plates are anatomically shaped and include "cross-elements" that form a three-dimensional scaffold in bone to enhance fixation stability. According to Neer classification, there were 24 two-part fractures, 49 three-part fractures and 20 four-part fractures (4 with dislocated heads). X-rays and Constant Shoulder Scores (CSS) were used to evaluate healing, complications, and clinical outcomes. Results were compared with a meta-analysis of similar studies reported in literature over the last 10 years. RESULTS Eighty-three patients with a minimum follow-up of 2 years had a mean CSS of 72 (53-90) graded as excellent for 23 patients (28%), good for 35 (42%), fair for 14 (17%), and poor for 11 (13%). Fractures healed without complication in 75 (91%) patients. Eight (9%) complications were observed, i.e., three avascular necrosis of the humeral head, one case of implant loosening, two cases of subacromial impingement and two superficial infections. There was no significant correlation between Neer fracture stage and patient outcome (p = 0.257). Compared to the literature, this method had a lower complication grade (p = 0.03), though it did not significantly differ in its clinical outcomes (p = 0.08). CONCLUSIONS The investigated plating system includes design features that can potentially increase utility for ORIF of proximal humeral fractures. While the complication profile was signficantly less than reported in the literature for standard proximal humerus plates, clinical outcomes were similar. Further studies will be required to better understand the role of plate design on treatment of these challenging fractures. LEVEL OF EVIDENCE IV, therapeutic study.
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Affiliation(s)
- Andrea Fidanza
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Orthopaedics and Traumatology, Piazzale S.Tommasi, 67100, L'Aquila, Italy.
| | - Costantino Rossi
- S.S. Filippo e Nicola Hospital, Unit of Orthopaedics and Traumatology, Via Di Vittorio, 67051, Avezzano, Italy
| | - Sergio Iarussi
- S.S. Filippo e Nicola Hospital, Unit of Orthopaedics and Traumatology, Via Di Vittorio, 67051, Avezzano, Italy
| | - Stefano Necozione
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Clinical Epidemiology, Piazzale S.Tommasi, 67100, L'Aquila, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery, Stanford University, PAVAHCS - Surgical Services, Palo Alto, CA, 94304, USA
| | - Vittorio Calvisi
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Orthopaedics and Traumatology, Piazzale S.Tommasi, 67100, L'Aquila, Italy
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Maccagnano G, Solarino G, Pesce V, Vicenti G, Coviello M, Nappi VS, Giannico OV, Notarnicola A, Moretti B. Plate vs reverse shoulder arthroplasty for proximal humeral fractures: The psychological health influence the choice of device? World J Orthop 2022; 13:297-306. [PMID: 35317248 PMCID: PMC8935332 DOI: 10.5312/wjo.v13.i3.297] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/06/2021] [Accepted: 02/19/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Proximal humeral fractures represent the third most common observed osteoporotic fracture; the treatment in three and four-part proximal humeral fractures in patients over 65 years is still controversial. Among the treatments described in literature, open reduction and internal fixation (O.R.I.F) and reverse shoulder arthroplasty (RSA) are gaining an increasing popularity. AIM To investigate the correct treatment for three and four-part proximal humeral fractures according to psychological aspects. METHODS It was conducted a prospective study with a series of 63 patients treated with O.R.I.F. (group A) and with RSA (group B) for three and four-part proximal humeral fractures according to Neer classification system. A conservative treatment group, as control, was finally introduced. One independent observer performed clinical and a psychological evaluation at one (T0), six (T1) and twelve months (T2) postoperatively. The Constant's score and The Disabilities of the Arm, Shoulder and Hand (DASH score) were used for clinical evaluation, while General Anxiety Disorder-7 (GAD-7) and Caregiver Strain Scale (CSS) were used for psychological evaluation. RESULTS At one month follow up in group A the mean values were DASH score 50.8, Constant score 36.1, GAD-7 score 5.4, CSS 5.0. For the group B, the average values at T0 were: DASH score 54.6, Constant score 32.0; GAD-7 score 6.4, CSS 6.2. At six months in group A the average values were DASH score 42.1, Constant score 47.3, GAD-7 score 4.3, CSS 3.9. For the group B, the average values at T1 were: DASH score 39.1, Constant score 43.2, GAD-7 score 5.7, CSS 5.5. At twelve months in the group A, the mean values were DASH score 32.8, Constant score 60.0, GAD-7 score 3.2, CSS 3.1. For the group B shown these mean values: DASH score 33.6, Constant score 52.9, GAD-7 score 4.3, CSS 4.5. We demonstrated a better clinical and psychological outcome at T2 in the group treated with osteosynthesis compared to the group treated with arthroplasty (Constant P = 0.049, GAD-7 P = 0.012 and CSS P = 0.005). A better clinical and psychological outcome emerged in control group at T2 comparing with surgical group (DASH score P = 0.014, Constant score P < 0.001, GAD-7 P = 0.002 and CSS P = 0.001). CONCLUSION Both open osteosynthesis and reverse shoulder arthroplasty are valid treatments for proximal humeral fractures. According to the best osteosynthesis results the authors suggested to perform a psychological analysis for each patient in order to choose the appropriate treatment.
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Affiliation(s)
- Giuseppe Maccagnano
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Surgery, University of Foggia, Orthopaedics Unit, General Hospital, Foggia 71122, Italy
| | - Giuseppe Solarino
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | - Vito Pesce
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Surgery, University of Foggia, Orthopaedics Unit, General Hospital, Foggia 71122, Italy
| | - Giovanni Vicenti
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | - Michele Coviello
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | | | - Orazio Valerio Giannico
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari 70124, Italy
| | - Angela Notarnicola
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | - Biagio Moretti
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
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Ling K, Kashanchi KI, VanHelmond T, Nazemi A, Kim M, Komatsu DE, Wang ED. Readmission, Reoperation, and Non-home Discharge Rates in Patients Receiving Surgical Treatment for Proximal Humerus Fractures. JSES Int 2022; 6:573-580. [PMID: 35813141 PMCID: PMC9264000 DOI: 10.1016/j.jseint.2022.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Proximal humerus fractures (PHFs) are generally surgically treated with open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Diverse fracture patterns and a high prevalence in the elderly population make it difficult to establish objective guidelines for the decision to undergo surgical treatment. The purpose of this study was to investigate risk factors associated with readmission, reoperation, and nonhome discharge following ORIF, HA, and TSA for PHFs. Methods Data on all patients who underwent ORIF, TSA, or HA for treatment of closed PHF between 2015 and 2017 were obtained by querying the American College of Surgeons National Surgical Quality Improvement database. Rates of postoperative readmission, nonhome discharge, and reoperation within 30 days were collected. Multivariate logistic regression was employed to identify predictors of readmission, nonhome discharge, and reoperation. Results A total of 2825 patients were included in this study: 1829 underwent ORIF, 707 underwent TSA, and 289 underwent HA. The significant predictors for readmission were having an American Society of Anesthesiologists class ≥ 3 (odds ratio [OR] 1.95, P = .003) and being of dependent functional status (OR 3.15, P < .001). The significant predictors for reoperation were male sex (OR 2.41, P < .001) and dependent functional status (OR 2.92, P = .006). The significant predictors for nonhome discharge were age 66-80 years (OR 7.00, P < .001), age ≥ 81 years (OR 16.31, P < .001), American Society of Anesthesiologists ≥3 (OR 2.34, P < .001), dependent functional status (OR 2.48, P < .001), and inpatient status (OR 3.32, P < .001). TSA showed slightly higher rates of nonhome discharge than HA and ORIF. Conclusion Significant risk factors for readmission, reoperation, and nonhome discharge within 30 days following surgical treatment for PHF were identified. Additionally, TSA was significantly associated with nonhome discharge compared with HA and ORIF.
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Affiliation(s)
- Kenny Ling
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Kevin I. Kashanchi
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Taylor VanHelmond
- Charles E. Schmidt College of Medicine at Florida Atlantic University, Boca Raton, FL, USA
| | - Alireza Nazemi
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Matthew Kim
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
- Corresponding author: Edward D. Wang, MD, Department of Orthopaedics, Stony Brook University Hospital, HSC T-18, Room 080, Stony Brook, NY 11794-8181, USA.
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Attala D, Primavera M, Di Marcantonio A, Broccolo L, Oliverio FP, Zoccali C, Baldi J, Biagini R. The role of minimally invasive plate osteosynthesis (MIPO) technique for treating 3- and 4-part proximal humerus fractures in the elderly - a case study. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021251. [PMID: 34487103 PMCID: PMC8477078 DOI: 10.23750/abm.v92i4.9985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 11/30/2022]
Abstract
Background and aim of the work: Proximal humeral fractures incidence in the elderly population is increasing. Treatment management is complicated by fracture complexity and patients’ comorbidities. The aim of our prospective study is the outcome evaluation of the role of minimally invasive plate osteosynthesis (MIPO) for elderly patients with a 3- or 4-parts proximal humeral fractures having an intact medial wall. Methods: N=45 patients were selected using inclusion criteria (>75yo, unilateral 3- or 4-parts proximal humeral fracture and with a surgical indication). We analyzed n=42 fractures treated with MIPO (3 patients had been reversed to ORIF and arthroplasty intraoperatively): n=20 4-parts fractures and n=22 were 3-parts. Of the 42 operated patients 17 identified as male and 25 as female (mean age 84yo). A trans-deltoid approach has been used with minimal surgical exposure and tissue damage to preserve the local tissue for early shoulder mobilization. Results: At follow-up, the DASH recorded mean value was 72, while the Constant mean score was 68. Complications have been recorded in 23,8% of patients with 4-parts fractures having the highest complication frequency. Mean shoulder joint ROM was recorded: anterior elevation 75°, lateral elevation 80°, abduction 90°, intra-rotation 50°, extra-rotation 25°. The following factors were identified influencing the outcome: >8mm calcar fragment, head valgus impaction and periosteal medial hinge preservation. Conclusions: The increase in population longevity matches the increase in complex humeral fracture frequency. We strongly for management consensus for proximal humerus fracture, in a similar way as for neck femoral fractures. MIPO is excellent in reducing soft tissue damage and complications for elderly patients with limited functional demand. (www.actabiomedica.it)
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Affiliation(s)
- Dario Attala
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy..
| | - Matteo Primavera
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy..
| | - Arianna Di Marcantonio
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy..
| | - Loris Broccolo
- Department of Orthopaedic and Traumatology, Ospedale Civile di Crotone, Via Bologna, 88900 Crotone, Italy..
| | - Francesco Pio Oliverio
- Department of Orthopaedic and Traumatology, Ospedale Civile di Crotone, Via Bologna, 88900 Crotone, Italy.
| | - Carmine Zoccali
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy..
| | - Jacopo Baldi
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy..
| | - Roberto Biagini
- Oncological Orthopaedics Department, Muscular-skeletal Tissue Bank, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome, Italy..
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10
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Mohan K, Hintze JM, Morrissey D, Molony D. Incidence of avascular necrosis following biceps tenodesis during proximal humerus open reduction and internal fixation. Acta Orthop Belg 2021. [DOI: 10.52628/87.2.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Avascular necrosis (AVN) may occur in up to 77% of proximal humeral fractures and can cause fixation failure. Risk factors include fracture position, calcar length and medial hinge integrity. We routinely perform intra-articular biceps tenotomy with tenodesis at the level of pectoralis major to facilitate fragment identification and potentially ameliorate post-operative pain relief. Concern exists that tenotomising the biceps damages the adjacent arcuate artery, potentially increasing the rate of AVN. The purpose of this study was to evaluate whether biceps tenodesis is associated with an increased risk of radiographically evident humeral head AVN.
61 fractures surgically treated over a 52-month period were retrospectively reviewed and radiographically assessed in accordance with Neer’s classification, calcar-length and medial hinge integrity.
40, 20 and 1 were four-, three- and two-part fractures respectively. 37 had a calcar-length less than 8mm and 26 suffered loss of the medial hinge. The median radiographic follow-up was 23 months. There was radiographic evidence of humeral head AVN in only one case, comparing favourably to rates quoted in current literature.
In our experience, intra-articular biceps tenotomy with the deltopectoral approach was thus not associated with a significantly increased risk of humeral head AVN, even in complex four-part fractures.
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11
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The value of lateral glenohumeral offset in predicting construct failure in proximal humerus fractures following internal fixation. J Shoulder Elbow Surg 2021; 30:819-825. [PMID: 32763382 DOI: 10.1016/j.jse.2020.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/12/2020] [Accepted: 07/19/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus fractures are the third most common osteoporosis defining injury in the United States, yet operative fixation of these injuries remains technically challenging. Although several modifiable and nonmodifiable risk factors are correlated with failure of proximal humerus fixation, no study has investigated whether failure to restore glenohumeral offset plays a part in fixation failure. The goals of this study are: (1) to determine if lateral glenohumeral offset (LGHO) and humeral head diameter (HHD) can be measured radiographically with accuracy between observers, (2) to observe whether there is a correlation between failure to operatively restore an anatomic LGHO:HHD ratio and failure of fixation, and (3) if there is a correlation, can any recommendations be made in regard to the ideal LGHO:HHD ratio. METHODS Retrospective review found 183 patients meeting inclusion criteria who underwent operative fixation for proximal humerus fractures between 2005 and 2018. Patients suffering construct failure requiring reoperation were compared with clinically successful surgeries on the basis of age, sex, fracture morphology, head-shaft angle, smoking history, presence or absence of a calcar screw, and LGHO:HHD ratio. The groups were compared using a combination of Student t-tests, χ2, and bivariate and multivariate logistic regression analyses where appropriate. The Student t-test and intraclass correlation coefficient were both used to assess interobserver reliability. RESULTS We found that LGHO and HHD can be measured by independent observers accurately (intraclass correlation coefficient = 0.80, 95% confidence interval: 0.65-0.89). Patients suffering implant failure had a significantly lower LGHO:HHD ratios compared with those who did not (0.94 vs. 1.03, P ≤ .001). The LGHO:HHD ratio was an independent predictor of implant failure even after controlling for other potential risk factors. Patients with an LGHO:HHD of 1.0 or above have a <10% chance of failure compared with a 20% risk with a ratio of 0.9 and a 40% risk at 0.8. CONCLUSION We found the LGHO:HHD ratio to be an independent predictor for construct failure after plate and screw fixation of proximal humerus fractures. Efforts should be made to restore an anatomic ratio of at least 1.0 to minimize the risk of failure.
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12
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Sahnoun N, Chtourou S, Rebai MA, Lajmi A, Hammami M, Chhaydar H, Hentati Y, Keskes H. [Surgical treatment of complex fractures of the upper end of the humerus: a retrospective study of 25 cases]. Pan Afr Med J 2020; 36:5. [PMID: 32550968 PMCID: PMC7282609 DOI: 10.11604/pamj.2020.36.5.22729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/17/2020] [Indexed: 11/20/2022] Open
Abstract
Les fractures de l’extrémité supérieure de l’humérus posent un problème thérapeutique particulièrement pour les fractures complexes à 3 et 4 fragments. Le but de notre travail est de déterminer l’aspect épidémio-clinique des fractures complexes de l’extrémité supérieure de l’humérus chez l’adulte et d’apprécier les résultats fonctionnels et radiologiques de notre série. Il s’agit d’une série de 25 cas colligés au service d’orthopédie CHU Habib Bourguiba entre 2012 et 2017. Nous avons recensé les données épidémiologiques des patients et les circonstances du traumatisme. Le traitement était de principe chirurgical soit ostéosynthèse par plaque ou clou soit un remplacement prothétique. La réduction a été évaluée sur les radiographies post opératoires. Au recul les résultats fonctionnels ont été évalués par le score de Constant. Notre série comporte 12 hommes et 13 femmes, La moyenne d’âge de nos patients était 55 ans, les accidents de la voie publique étaient notés dans 48%, Les fractures à 4 fragments ont été retrouvées dans 76% des cas. L’ostéosynthèse par plaque vissée a été utilisée dans 40% des cas et l’enclouage antérograde a été réalisé dans 40% des cas. La prothèse a été posée pour 5 patients. Le score de constant moyen était de 65,24 avec des extrêmes allant de 35 à 88. Nous avons noté une consolidation des fractures sans cal vicieux dans 68%. Dans les fractures complexes de l’extrémité supérieure de l’humérus, une ostéosynthèse bien indiquée selon le patient et la fracture et une rééducation post opératoire précoce permettent d’avoir des résultats fonctionnels acceptables.
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Affiliation(s)
- Nizar Sahnoun
- Service de Chirurgie Orthopédique et Traumatologie, CHU Habib Bourguiba Sfax, Sfax, Tunisie
| | - Sami Chtourou
- Service de Chirurgie Orthopédique et Traumatologie, CHU Habib Bourguiba Sfax, Sfax, Tunisie
| | - Mohamed Ali Rebai
- Service de Chirurgie Orthopédique et Traumatologie, CHU Habib Bourguiba Sfax, Sfax, Tunisie
| | - Achraf Lajmi
- Service de Chirurgie Orthopédique et Traumatologie, CHU Habib Bourguiba Sfax, Sfax, Tunisie
| | - Mourad Hammami
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital Tataouine, Tataouine, Tunisie
| | | | - Yosr Hentati
- Service de Radiologie CHU Hedi Chaker Sfax, Sfax, Tunisie
| | - Hassib Keskes
- Service de Chirurgie Orthopédique et Traumatologie, CHU Habib Bourguiba Sfax, Sfax, Tunisie
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13
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Douleh DG, Stoneback JW, Bravman JT. Successful Open Reduction and Internal Fixation of Proximal Humerus Fracture After Dysvascular Subcoracoid Humeral Head Dislocation: A Case Report. JBJS Case Connect 2020; 10:e0313. [PMID: 32044782 DOI: 10.2106/jbjs.cc.18.00313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present the case of a 36-year-old patient with a 4-part proximal humerus fracture with subcoracoid dislocation and devascularization of the humeral head after a fall onto his right shoulder. CONCLUSION The patient was successfully treated with open reduction and locking plate fixation to demonstrate that a successful postoperative functional outcome with humeral head survival can be achieved in these complex situations.
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Affiliation(s)
- Diana G Douleh
- Division of Trauma and Fracture Surgery, Department of Orthopedics, University of Colorado, Aurora, Colorado.,Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado, Aurora, Colorado
| | - Jason W Stoneback
- Division of Trauma and Fracture Surgery, Department of Orthopedics, University of Colorado, Aurora, Colorado
| | - Jonathan T Bravman
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, University of Colorado, Aurora, Colorado
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14
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Wang JQ, Jiang BJ, Guo WJ, Zhao YM. Serial changes in the head-shaft angle of proximal humeral fractures treated by placing locking plates: a retrospective study. BMC Musculoskelet Disord 2018; 19:420. [PMID: 30497479 PMCID: PMC6267827 DOI: 10.1186/s12891-018-2349-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/19/2018] [Indexed: 11/24/2022] Open
Abstract
Background Although the proximal humeral fractures (PHFs) treated with locking plate have been well applied, there are few studies concerning on the serial HSA changes after locking plate placement. The purpose of this retrospective study was to explored the clinical significance of serial HSA changes after surgery. Methods We retrospectively analyzed the clinical data of 122 patients between January 2012 to December 2016 in our hospital. The serial change of the HSA and Neer’s score of 122 patients were recorded and analyzed. Then, we evaluated the HSA changes affected functional recovery in conjunction with medial support (MS). Moreover, multivariable linear regression analysis was performed to identify any potential confounding factors that may influence functional recovery. Results Of 146 patients, 122 (50 males and 72 females) patients were finally enrolled in our study. Our preliminary data suggested that the most decrease of HSA occurred in the period of 1 to 3 months (p < 0.001) postoperatively, and functional recovery was significantly related with the change of HSA (R2 = 0.647, p < 0.001). The presence of MS plays an important role in maintaining postoperative HSA and restoring function. Moreover, Neer type 4 fracture, the difference between the postoperative HSA (on the injured side) and that of the uninjured side (the ΔHSA), and the HSA change to the end of follow-up were all significantly associated with functional recovery. Conclusions Serial HSA changes were evident in PHF patients in whom locking plates had been inserted; it is essential to maintain reduction for 1–3 months postoperatively. MS is important in this context and surgeons must maximally restore MS. Furthermore, the functional outcome tended to improve when the HSA of the injured side was restored to a value close to that of the uninjured side.
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Affiliation(s)
- Ji-Qi Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Bing-Jie Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Wei-Jun Guo
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - You-Ming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China.
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15
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Padolino A, Porcellini G, Guollo B, Fabbri E, Kiran Kumar GN, Paladini P, Merolla G. Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes. Musculoskelet Surg 2018; 102:49-56. [PMID: 30343471 DOI: 10.1007/s12306-018-0562-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/05/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates. MATERIALS AND METHODS Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically. RESULTS Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group). CONCLUSIONS CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.
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Affiliation(s)
- A Padolino
- Shoulder and Elbow Unit, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy
| | - G Porcellini
- Shoulder and Elbow Unit, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy
| | - B Guollo
- Shoulder and Elbow Unit, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy
| | - E Fabbri
- Research and Innovation Department - AUSL della Romagna, Ambito Territoriale di Rimini, Rimini, Italy
| | - G N Kiran Kumar
- Shoulder and Elbow Unit, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy
| | - P Paladini
- Shoulder and Elbow Unit, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy
| | - G Merolla
- Shoulder and Elbow Unit, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy.
- Biomechanics Laboratory, Cervesi Hospital, Cattolica - AUSL della Romagna, Ambito Territoriale di Rimini, Cattolica, Italy.
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16
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Percutaneous fixation of valgus displaced fracture of the proximal humerus using a single screw. Orthop Traumatol Surg Res 2018; 104:67-70. [PMID: 29246482 DOI: 10.1016/j.otsr.2017.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 10/03/2017] [Accepted: 11/07/2017] [Indexed: 02/02/2023]
Abstract
Valgus-impacted proximal humerus fracture is a classic but rare entity in shoulder traumatology. Surgical treatment is controversial, with increasing use of minimally invasive techniques. Our technique uses a minimally invasive approach under fluoroscopic control. Raising the humeral head to reduce the valgus enables spontaneous and well-positioned reduction of the tuberosities and screw fixation between the greater tuberosity and the humeral shaft. Indications comprise valgus-impacted fracture without comminution of the medial epiphyseal-metaphyseal hinge or greater tuberosity; the rotator cuff contributes to reduction and must be intact. This type of fixation restores proximal humerus anatomy and achieves consolidation with low risk of secondary necrosis. Minimally invasive single-screw fixation is an alternative of choice for surgical treatment of valgus-impacted proximal humerus fracture.
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17
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Gregory TM, Gregory J, Nicolas E, Pierrart J, Masmejean E. Shoulder Arthroplasty Imaging: What's New. Open Orthop J 2017; 11:1126-1132. [PMID: 29152007 PMCID: PMC5675998 DOI: 10.2174/1874325001711011126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/10/2017] [Accepted: 05/14/2017] [Indexed: 11/22/2022] Open
Abstract
Background Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes. Method This article is a review article declining recent imaging processes for shoulder arthroplasty. Results Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation. Conclusion Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening.
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Affiliation(s)
- T M Gregory
- Upper Limb Surgery Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France.,Department of Mechanical Engineering, Imperial College, London, UK
| | - J Gregory
- Department of Radiology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris Descartes Paris, France
| | - E Nicolas
- Upper Limb Surgery Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
| | - J Pierrart
- Upper Limb Surgery Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
| | - E Masmejean
- Upper Limb Surgery Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
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18
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Touloupakis G, Stuflesser W, Ferrara F, Maione A, Antonini G, Crippa C. Early-stage radiological critical analysis of unsuccessful cases following a four-part fracture osteosynthesis of the proximal humerus: focus on the "P" sign. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:178-184. [PMID: 28845833 PMCID: PMC6166154 DOI: 10.23750/abm.v88i2.5295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/11/2016] [Indexed: 11/23/2022]
Abstract
Radiological evaluation of complex intra-articular fractures of the proximal humerus is still challenging. Here, we describe the post-operative "P" sign as a reproducible radiographical mark of a varus reduction, performed by assembling a head-shaft angulation of less than 130 degrees. Our retrospective study was conducted in a group of subjects who previously suffered from proximal humerus four-part fractures. We evaluated the post-operative evolution of specific radiographical parameters that are of crucial prognostic significance: Cervix-diaphysis angle (HHSA), quality level of the orthopaedic reduction (insufficient, sufficient and good) based on a radiological generalized subjective overview, presence of calcar screws through the Philos plate. The final cohort included a group of 39 patients of 70.76 ± 8.3 years of age and an average follow-up of 7.2 months. The post-operative mean HHSA was 131.5 ± 9.4. Interestingly, a positive correlation was detected between presence of the radiographical "P" sign in the post-operative period and the number of surgical complications coming up in the post-operative period (OR: 3.68 - I.C. 95%: 0.7984255-19.2532430), although not statistically significant. In our study, the high number of complications corresponds to literature database. Presence of the "P" sign could be a useful tool for assessing the quality of reduction during intra and post-operative radiological evaluation. We underline the importance of the "P" sign as a "quality of reduction" factor and strongly recommend its intra-operative monitoring as an additional tool together with a standard subjective evaluation of the reduction.
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Affiliation(s)
- Georgios Touloupakis
- Department of Orthopedics and Traumatology, San Carlo Borromeo Hospital, Milan, Italy.
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19
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Comparison of Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation on Proximal Humeral Fracture in Elder Patients: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3431609. [PMID: 28698871 PMCID: PMC5494086 DOI: 10.1155/2017/3431609] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/23/2017] [Indexed: 11/20/2022]
Abstract
Objective The study aims to compare minimally invasive percutaneous plate osteosynthesis (MIPO) and open reduction internal fixation (ORIF) in the treatment of proximal humeral fracture in elder patients. Method PubMed, Medline, EMbase, Ovid, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wangfang, and VIP Database for Chinese Technical Periodicals were searched to identify all relevant studies from inception to October 2016. Data were analyzed with Cochrane Collaboration's Review Manage 5.2. Results A total of 630 patients from 8 publications were included in the systematic review and meta-analysis. The pooled results showed that MIPO was superior to ORIF in the treatment of proximal humeral fracture in elder patients. It was reflected in reducing blood loss, operation time, postoperative pain, or fracture healing time of the surgery and in improving recovery of muscle strength. Concerning complications, no significant difference was seen between MIPO and ORIF. Conclusion The MIPO was more suitable than ORIF for treating proximal humeral fracture in elder patients.
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20
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Caforio M, Maniscalco P. The importance of early rehabilitation in proximal humeral fracture: A clinical trial of efficacy and safety of a new endomedullary nail. J Back Musculoskelet Rehabil 2017; 30:195-202. [PMID: 27392846 DOI: 10.3233/bmr-160732] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of the surgical treatment in proximal humeral fractures is to maintain bone alignment facilitating an early shoulder mobilization. This can be obtained with the use of an endomedullary nail with specific characteristics: a proximal angular multiplanar stability and the possibility to place proximal screws in the calcar region. The objective of this randomized controlled trial is to investigate the effects of an early rehabilitation program in 3-part proximal humeral fractures treated with endomedullary nailing. MATERIALS AND METHODS 126 patients treated with the Diphos Proximal Humeral Nail (PHN), followed with an Intensive Rehabilitation Program (IRP) started in the second postoperative day, were compared to 62 patients with a Standard Rehabilitation Program (SRP) where shoulder mobilization started after 3 weeks. The age of patients was under 65 years. Main Outcome measures were improvement of shoulder function based on Constant Score and quality of life on DASH questionnaire at 1, 3, 6 and 12 months after surgery. Safety outcome was no loss of radiological reduction at any follow-up control. RESULTS A difference considered statistically significant (95% confidence interval) was demonstrated by Constant scores at 3 and 6 months and by DASH questionnaire scores at 1 month after surgery between IRP and SRP groups, however without loss of radiological reduction and maintaining the full fracture healing at the same mean period of 1,8 ± 0,7 months. DISCUSSION This experience allows to highlight essential features of this new kind of endomedullary humeral nail, by its mechanical properties, in proximal humeral fractures in order to permit an early rehabilitation without creating displaced or consolidation delay. LEVEL OF EVIDENCE III, randomized clinical-case-control study.
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21
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Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases. Orthop Traumatol Surg Res 2016; 102:963-970. [PMID: 27818186 DOI: 10.1016/j.otsr.2016.09.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 07/07/2016] [Accepted: 09/06/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other. MATERIAL AND METHODS This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN). RESULTS After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group. CONCLUSION If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area. LEVEL OF EVIDENCE IV, retrospective study.
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Jin L, Guo J, Guo J, Yin Y, Hou Z, Zhang Y. Clinical Effects of the Probing Method with Depth Gauge for Determining the Screw Depth of Locking Proximal Humeral Plate. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5898161. [PMID: 27975055 PMCID: PMC5126400 DOI: 10.1155/2016/5898161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022]
Abstract
Background. The use of locking plates has gained popularity to treat proximal humeral fractures. However, the complication rates remain high. Biomechanical study suggested that subchondral screw-tip abutment significantly increased the stability of plant. We present a simple method to obtain the proper screw length through the depth gauge in elderly patients and compared the clinical effects with traditional measuring method. Methods. 40 patients were separated into two groups according to the two surgical methods: the probing method with depth gauge and the traditional measuring method. The intraoperative indexes and postoperative complications were recorded. The Constant and Murley score was used for the functional assessment in the 12th month. Results. Operative time and intraoperative blood loss indicated no statistical differences. X-ray exposure time and the patients with screw path penetrating the articular cartilage significantly differed. Postoperative complications and Constant and Murley score showed no statistical differences. Conclusions. Probing method with depth gauge is an appropriate alternative to determine the screw length, which can make the screw-tip adjoin the subchondral bone and keep the articular surface of humeral head intact and at the same time effectively avoid frequent X-ray fluoroscopy and adjusting the screws.
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Affiliation(s)
- Lin Jin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Jialiang Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Junfei Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Yingchao Yin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China
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Use of three-dimensional fluoroscopy to determine intra-articular screw penetration in proximal humeral fracture model. J Shoulder Elbow Surg 2014; 23:1150-5. [PMID: 24581875 DOI: 10.1016/j.jse.2013.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/31/2013] [Accepted: 12/03/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humeral locking plates have significantly improved the treatment of proximal humeral fractures in recent years; however, they are not devoid of complications. Inadvertent screw penetration into the joint is a well-documented complication. Intraoperative 3-dimensional (3D) imaging may assist in detecting intra-articular implant penetration. This study compared the performance of a standard C-arm fluoroscope with a novel 3D imaging fluoroscope in detecting penetrating implants in a proximal humeral fracture model. METHODS Zinc-sprayed proximal humerus sawbones were affixed with a proximal humeral locking plate. Six different constructs were assembled. In each specimen, 1 screw, 2 screws, or no screws were inserted 2-mm proud of the articular surface. Each specimen was imaged with a conventional fluoroscope and a 3D imaging fluoroscope. Overall, 36 image sets were prepared for each modality. These were evaluated by 2 fellowship-trained surgeons for intraobserver and interobserver reliability as well for the accuracy of detecting prominent implants in the 2 imaging methods. RESULTS Overall accuracy for observer A was 89.9% compared with 100% for C-arm fluoroscopy and 3D imaging fluoroscopy (P < .01) and for observer B was 91.1% and 100% (P = .01), respectively. The κ values were 0.74 with C-arm fluoroscopy and 1.0 for the 3D imaging fluoroscopy for observer A, and 0.93 and 1.0, respectively, for observer B. CONCLUSIONS In a proximal humeral fracture model, C-arm fluoroscopy is a highly accurate imaging modality that can minimize the incidence of penetrating screws into the joint. Further clinical studies are required to establish this modality.
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Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res 2014; 472:2317-24. [PMID: 24733446 PMCID: PMC4079887 DOI: 10.1007/s11999-014-3613-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND With technologic advances such as locked periarticular plating, hemiarthroplasty of the humeral head, and more recently reverse total shoulder replacement, surgical treatment of proximal humerus fractures has become more commonplace. However, there is insufficient information regarding patient outcomes after surgery, such as the frequency of unplanned hospital readmissions and factors contributing to readmission. QUESTIONS/PURPOSES We measured (1) the frequency of unplanned hospital readmissions after surgical treatment of proximal humerus fractures, (2) the medical and surgical causes of readmission, and (3) the risk factors associated with unplanned readmissions. METHODS The State Inpatient Database from seven different states was used to identify patients who underwent treatment for a proximal humerus fracture with open reduction and internal fixation (ORIF), hemiarthroplasty of the humeral head, or reverse total shoulder arthroplasty from 2005 through 2010. The database was used to measure the 30-day and 90-day readmission rates and identify causes and risk factors for readmission. Multivariate modeling and a Cox proportional hazards model were used for statistical analysis. RESULTS A total of 27,017 patients were included with an overall 90-day readmission rate of 14% (15% for treatment with ORIF, 15% for reverse total shoulder arthroplasty, and 13% for hemiarthroplasty). The majority of readmissions were associated with medical diagnoses (75%), but treatment with ORIF was associated with the most readmissions from surgical complications, (29%) followed by reverse total shoulder arthroplasty (20%) and hemiarthroplasty (16%) (p < 0.001). Risk of readmission was greater for patients who were female, African American, discharged to a nursing facility, or had Medicaid insurance. CONCLUSIONS As the majority of unplanned hospital readmissions were associated with medical diagnoses, it is important to consider patient medical comorbidities before surgical treatment of proximal humerus fractures and during the postoperative care phase. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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