Biomechanical comparison of a unique locking plate versus a standard plate for internal fixation of proximal humerus fractures in a cadaveric model

BACKGROUND: Newer internal fixation devices with a locking mechanism between the plate and the screw have recently been released. The efficacy of these plates in the proximal humerus has yet to be fully described. There is a need to compare the biomechanical properties of efficacy of plate fixation with or without locking screws for surgery of two-part proximal humerus fractures. Multiple-plane locking plate and cloverleaf plate designs were tested to determine their ability to maintain fixation on the humeral head. METHODS: Eight matched pairs of cadaveric shoulders with 7-millimeter osteotomy defects at the surgical neck simulating two-part fractures of the proximal humerus were loaded to failure in thirty degrees of glenohumeral abduction. One side was repaired with a proximal humerus locking plate and the other with a cloverleaf plate. The rotator cuff musculature was then loaded via a servo-hydraulic testing machine under displacement control to simulate the deforming forces present in vivo. FINDINGS: The average maximum load to failure was greater in proximal humerus locking plates than in cloverleaf plates (876 versus 712; P=0.04). INTERPRETATION: In the cadaveric, two-part proximal humerus fracture model that was created, the locking plate displayed significantly greater holding power of the humeral head. Clinical relevance is unproven but may be manifested in vivo as improved early range of motion exercises and functional outcome.     

长型肱骨近端锁定钢板治疗肱骨近端并肱骨干骨折

背景：国内外均有文献报道证实长型肱骨近端内固定锁定钢板用于治疗肱骨近端骨折疗效显著. 目的：总结应用长型肱骨近端内固定锁定钢板手术治疗肱骨近端合并肱骨干骨折的临床疗效. 方法：纳入应用长型肱骨近端内固定锁定钢板治疗肱骨近端合并肱骨干骨折患者16例.其中男7例,女9例,年龄45-83岁,平均71岁.肱骨近端Neer分型,2部分骨折5例,3部分骨折8例,4部分骨折3例;肱骨干骨折AO分型A1型5例,B1型6例,B2型2例,C1型2例,C3型1例.内固定后肩关节功能采用Constant-Murley肩关节评分标准对患者两侧肩关节进行评分,同时计算评分百分比并作相应评价.肘关节采用改良HSS评分标准评估. 结果与结论：16例患者均获随访,随访时间12-24个月,平均14.9个月.所有患者骨折均愈合,时间8-17周,平均12.1周.2例患者出现伤口脂肪液化,换药后均愈合.1例患者治疗后出现桡神经麻痹症状,1例患者出现肩峰撞击综合征,治疗后好转.无内固定松动、螺钉切割及肱骨头缺血坏死等并发症发生.治疗后12个月按 Constant-Murley 评分标准为65-90分,平均76.87分.与健侧百分比为71.4%-93.8%,平均83.41%.优良15例,满意1例.改良HSS肘关节评分优13例,良3例,优良率100%.说明长型PHILOS钢板治疗肱骨近端合并肱骨干骨折固定可靠,并发症少,疗效满意.     

Proximal humerus fracture rotational stability after fixation using a locking plate or a fixed-angle locked nail: The role of implant stiffness

Background

Fixed-angle locked devices have been developed to improve internal fixation of proximal humerus fractures. Available low-profile precontoured locking plates and intramedullary nails with fixed-angle interlocks are currently favored by most surgeons in this setting. The aim of this study was to assess the relative stability of these two methods of fixation under torsion load.

Methods

A surgical neck osteotomy was created in six pairs of embalmed humeri. In each pair, one specimen was secured with a titanium locking-compression plate, and the contralateral was secured with a titanium nail with a proximal locked spiral blade. The specimens were first tested cyclically in internal–external rotation for 10,000 cycles to evaluate interfragmentary motion (dynamic study). At the end of the cyclic testing, the specimens were loaded to failure in external rotation to measure torque to failure and construct stiffness (static study).

Findings

There were no significant differences in interfragmentary motion between the two fixation devices in the dynamic study. When tested to failure, fixation with the locking plate tolerated on average 20 more degrees in torsion before failure, and demonstrated higher torsional load to failure and less torsional stiffness (P < 0.05).

Interpretation

Both locking plates and locked intramedullary nails may provide enough stability to avoid secondary displacement of proximal humerus fractures during early physical therapy. Locking plates demonstrated superior biomechanical properties under high rotational loads than locked intramedullary nails in a cadaveric proximal humerus two-part osteotomy model, and could provide more protection against unexpected high torsion loads.     

Biomechanical study of Proximal humeral fracture fixation: Locking plate with medial support screw vs. locking plate with intramedullary fibular graft

BackgroundThe purpose of this study was to evaluate the biomechanical properties of two different fixation constructs in varus collapse proximal humerus fracture, locking plate with medial support screw and locking plate with intramedullary fibular graft.MethodsWe used 8 pairs of undamaged fresh-frozen humen cadaveric humeri and fibula from patients ranging in age from 62 to 81 years. We simulated a proximal humerus fracture with medial comminution using wedge shaped osteotomy. One group was fixed with locking plate with medial support screws, the other group with locking plate with intramedullary fibular graft. Biomechanical test was carried out using servohydraulic material testing system. We measured displacement of specimens under cyclic load test, maximum failure load, initial stiffness, and mode of failure under increasing load test.FindingsUnder cyclic loading, the displacement of the specimen was significantly less in the locking plate with fibular strut graft group than in the locking plate with medial support screws group. (p = 0.012) Under increasing load test, the Locking plate with fibular strut graft group showed higher values in both maximum failure load and initial stiffness than the Locking plate with medial support screws group, and this was statistically significant. (p = 0.012, p = 0.001).InterpretationIn biomechanical study, the locking plate with fibular strut graft showed significantly better results in all of the maximum failure load, initial stiffness, and gap depletion compared to the locking plate with medial support screws.Level of evidenceLevel IV.     

Open reduction internal fixation of proximal humerus fractures

The treatment of proximal humerus fractures continues to evolve. While the many of these injuries can be managed nonoperatively, a certain percentage require operative treatment. Open reduction internal fixation can offer excellent outcomes when performed in the appropriate patient and utilizing proper techniques. This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes.     

老年肱骨近端骨折骨水泥加钢板固定术的护理配合

目的:探讨应用骨水泥加钢板固定治疗老年肱骨近端不稳定性骨折的护理配合方法,以提高手术配合质量。方法:总结21例肱骨近端骨折患者手术护理配合经验。结果:21例手术均配合成功,未发生与护理相关的并发症。结论:掌握骨水泥加钢板固定治疗老年肱骨近端不稳定性骨折的手术特点,做好完善的术前准备、准确的术中配合、严格的无菌管理是配合手术成功的保证。     

正骨手法结合MIPPO技术重建肱骨近骨折端内侧柱稳定的临床应用

目的:探讨正骨手法闭合复位结合经皮微创固定(MIPPO)重建肱骨近端骨折内侧柱稳定的临床研究。方法:采用正骨手法闭合复位结合经皮锁定钢板固定重建肱骨内侧柱稳定治疗肱骨近端骨折34例。记录术后3、6、12个月骨折恢复情况,内固定是否松动断裂,肱骨头有无缺血坏死,内固定取出时间和内固定取出后局部骨质情况以及有无再骨折。术后应用Constant-Murley评分系统对肩关节进行评定。结果:术后所有患者切口均愈合并获随访,时间8~21个月,平均16.7个月。1例患者术后出现腋神经损伤症状,6个月后症状消失;1例患者术后2个月出现肱骨头内翻畸形,但螺钉尚在肱骨头内,未予翻修,骨折畸形愈合,术后12个月拆除内固定,肩外展功能受限明显;1例患者术后1年出现肱骨头缺血性坏死,二期拆除内固定,行肱骨头置换;余患者术后6~9个月骨性愈合,摄片复查骨皮质连续,重塑良好。总分比较:3个月与6个月比较,P0.05,差异有统计学意义。术后12个月根据Constant-Murley评分,总分75~88分,良21例,中13例。结论:正骨手法整复经皮微创锁定钢板固定治疗肱骨近端骨折,重建内侧柱稳定,具有创伤小、血循破坏少、固定可靠等优点,是治疗肱骨近端骨折的有效方法。     

经皮钢板与解剖锁定钢板置入内固定治疗肱骨近端骨折

背景：对于肱骨近端骨折或者严重并发症的患者,需要通过内固定物置入达到有效的固定,这样不会影响到肩关节的活动功能,而且创伤小。目的：探讨经皮钢板内固定联合解剖锁定钢板置入内固定治疗肱骨近端骨折的生物力学特征。方法：选取广州医科大学附属第三医院骨科2007年3月至2011年12月收治的肱骨近端骨折患者75例,观察锁定钢板治疗后的愈合以及内固定后肩关节评分。分析锁定钢板治疗肱骨近端骨折在生物力学方面的优势。结果与结论：①75例患者治疗后均获得随访,随访时间6-24个月,平均13.3个月。②治疗后X射线片显示所有螺钉位置良好,骨折复位满意,骨折均得到了愈合,未发生神经血管损伤以及肱骨头坏死的病例,其中1例出现感染经治疗痊愈,72例无肩痛,3例偶有肩痛。③Neer评分优57例,良11例,中7例,差0例,优良率为90.7%。与其它内固定物比较,锁定钢板治疗肱骨近端骨折的固定强度大,疗效满意,已成为临床治疗肱骨近端骨折的首选。     

3D打印技术联合肱骨近端锁定钢板内固定对肱骨近端骨折患者术后VAS评分及肩关节功能的影响

目的探讨3D打印技术联合肱骨近端锁定钢板内固定对肱骨近端骨折患者术后疼痛视觉模拟量表(VAS)评分及肩关节功能的影响。方法将我院收治的80例肱骨近端骨折患者以随机数字表法分为内固定组(40例,肱骨近端锁定钢板内固定术)和联合组(40例,3D打印技术联合肱骨近端锁定钢板内固定术)。比较两组的治疗效果。结果联合组的术中出血量及术后引流量均少于内固定组,手术时间短于内固定组(P<0.05)。两组术后12 h VAS评分、骨折愈合时间、治疗总有效率无显著差异(P>0.05)。术后6个月,联合组股骨头高度丢失、股骨头内翻角小于内固定组,股骨颈干角大于内固定组(P<0.05)。术后6个月,联合组的肩关节功能优良率大于内固定组(P<0.05)。结论3D打印技术联合肱骨近端锁定钢板内固定治疗肱骨近端骨折,可减少术中出血量,缩短手术时间,降低术后引流量,最大程度重建内侧距支撑,改善患者的肩关节功能。     

手法结合MIPPO技术重建内侧柱稳定治疗骨质疏松性肱骨近端骨折的对照研究

【】目的：探讨正骨手法闭合复位结合经皮微创固定(mippo)治疗老年肱骨近端骨折的临床研究。方法：2014年10月至2016年1月,采用正骨手法闭合复位,经皮锁定钢板固定重建肱骨内侧柱稳定治疗老年肱骨近端骨折40例,分为手法组和切复组,记录术后3、6、12个月骨折恢复情况,内固定是否松动断裂,肱骨头有无缺血坏死,内固定取出时间及内固定取出后局部骨质情况、以及有无再骨折。术后应用Constant-Murley评分系统对肩关节进行评定。结果：40例患者均获随访,手法组1例患者术后出现肱骨头内翻畸形,骨折畸形愈合,1例患者出现肱骨头缺血性坏死;切复组2例患者出现肱骨头内翻,1例行肱骨头置换术,另1例行内固定拆除;肩关节功能Constant-Murley评分2组术后比较差异较大,术后12个月根据Constant-Murley评分,两组总分分别为平均为82-93分与77-85分。结论：正骨手法整复经皮微创锁定钢板固定治疗肱骨近端骨折,重建内侧柱稳定,具有创伤小、血循破坏少、固定可靠等优点,是治疗老年性肱骨近端骨折的有效方法。     

锁定钢板与人工肱骨头置换治疗成人肱骨近端骨折疗效的Meta分析

目的对采取锁定钢板与人工肱骨头置换治疗成人肱骨近端骨折的临床疗效进行Meta分析,探讨两种手术方式的治疗效果。方法通过计算机检索中国生物医学文献数据库(CBM)、中文万方数据库、维普数据库(VIP)、中国知网(CNKI)及外文PubMed、Science Direct等数据库2004年1月至2013年12月期间发表的相关治疗肱骨近端骨折的各种对照研究,进行Meta分析。结果共纳入符合标准的文献9篇,采用Review Manager 5.2软件进行Meta分析,结果显示:锁定钢板与人工肱骨头置换比较Neer评分优良率方面差异无统计学意义(OR=0.84,95%CI:0.33~2.14,P=0.72),在ASES评分优良率方面无显著差异(OR=0.80,95%CI:0.26~2.44,P=0.69)。结论目前认为锁定钢板与人工肱骨头置换对特定骨折类型各有利弊。对于高龄粉碎性的肱骨近端骨折患者,多数倾向于人工肱骨头置换。对于老年粉碎性的肱骨近端骨折的患者,现有文献中没有足够的对照试验证明人工肱骨头置换的优越性。     

Biomechanical evaluation of a new fixation technique for internal fixation of three-part proximal humerus fractures in a novel cadaveric model

Background

The optimal surgical treatment for displaced proximal humeral fractures is still controversial. A new implant for the treatment of three-part fractures has been recently designed. It supplements the existing Expert Humeral Nail with a locking plate. We developed a novel humeral cadaveric model and the existing implant and the prototype were biomechanically compared to determine their ability in maintaining interfragmentary stability.

Methods

The bone mineral density of eight pairs of cadaveric humeri was assessed and a three-part proximal humeral fracture was simulated with a Greater Tuberosity osteotomy and a surgical neck wedge ostectomy. The specimens were randomly assigned to either treatment. A bone anchor simulated part of a rotator cuff tendon pulling on the Greater Tuberosity. Specimens were initially tested in axial compression and afterward with a compound cyclic load to failure. An optical 3D motion tracking system continuously monitored the relative interfragmentary movements.

Findings

The specimen stabilized with the prototype demonstrated higher stiffness (P = 0.036) and better interfragmentary stability (P values < 0.028) than the contralateral treated with the existing implant. There was no correlation between the bone mineral density and any of the investigated variables.

Interpretation

The convenience of this new IM-nail and locking plate assembly must be confirmed in vivo but the current study provides a biomechanical rationale for its use in the treatment of three-part proximal humeral fractures. The improved stability could be advantageous in particular when medial buttress is missing, even in osteoporotic bone.     

Investigation of the geometries of the coronoid process and the fibular allograft as a potential surgical replacement

Background

The proximal tibiofibular joint can be used as a source of osteochondral autograft with little to no morbidity at the harvest site.

Methods

CT scans of fourteen left and seven right fibular heads, seven right and six left ulnas obtained from healthy subjects were volume-scaled and analyzed. Ipsilateral ulnar articular surfaces were compared between subjects and contralateral ulnas were compared within the same subject. The average deviations between the surfaces were measured. Manual registration and best-fit alignment were used to locate the area on the fibular heads that would best-fit the 50% coronoid process surface.

Findings

The average deviations in the articular surface between subjects were (mean (SD) 0.79 mm (0.17) and 0.76 mm (0.14) for the left and right ulnas respectively and 0.35 mm (0.07) in the same subject. The average coronoid process height of the scaled ulnas was 15.92 mm (1.15). When comparing the 50% coronoid process with the ispsilateral fibular head geometries, the maximum deviations for all subjects were smaller than 2.0 mm. Two locations were identified as the best-fit locations.

Interpretation

When volume-scaled, the articular congruency of the proximal ulna articular surfaces between subjects is within the allowable limit for a typical intra-articular fracture step. Results suggest it is possible to use the CT scan of a patient's contralateral elbow as a template to estimate the morphology of the affected side. The fibular head could be an alternative replacement for damaged coronoid process since it is covered by articular cartilage and has locations with a similar curvature as the coronoid process.     

经皮微创置入肱骨近端锁定接骨板的术后护理与康复锻炼

目的 总结经皮微创置入肱骨近端锁定接骨板治疗肱骨近端骨折的术后护理与康复指导方法.方法 对22例经皮微创手术内固定治疗肱骨近端骨折患者,在术后不同阶段给予护理与康复指导,包括一般护理、引流管与伤肢管理、疼痛护理和阶段性康复训练指导.结果 20例患者平均随访20(10～32)个月,未发现肱骨头坏死及腋神经损伤病例,无内固定松动,骨折均得到了愈合,平均骨折愈合时间为15(11～20)周.2例有10°以下的轻度内外翻畸形.根据美国肩肘外科医师评估标准,优良率为89.35％.结论 对于经皮微创置入肱骨近端锁定接骨板治疗肱骨近端骨折的患者来说,术后有效的护理与循序渐进的康复锻炼是手术成功的重要因素.     

应用T型锁定加压钢板手术治疗胸骨骨折

目的探讨应用T型锁定加压钢板治疗胸骨骨折的疗效。方法对12例严重移位胸骨骨折患者采用T型锁定加压钢板手术内固定治疗,观察治疗效果。结果所有患者痊愈出院,均无明显手术并发症。结论对于严重胸骨骨折患者,采用锁定加压钢板固定是一种效果非常好的方法,值得临床推广应用。     

锁定钢板结合自体髂骨打压植骨固定治疗肱骨近端四部分骨折的临床效果

目的分析研究锁定钢板结合自体髂骨打压植骨治疗肱骨近端四部分骨折的临床疗效。方法对14例肱骨近端四部分骨折患者采用锁定钢板结合自体髂骨打压植骨固定治疗。结果 14例患者术后6个月经Neer功能评分,良7例,可5例,差2例,综合优良率85.71%。结论锁定钢板结合自体髂骨打压植骨固定治疗肱骨近端四部分骨折具有较高的复位满意度,且具有固定牢固、并发症少、患肢功能恢复快、恢复时间短等优势,患者在术后短期即可开始康复训练,提升了患者手术成功率。     

锁定接骨板治疗老年患者肱骨近端骨折

目的:探讨锁定接骨板治疗老年患者的手术方式和临床疗效。方法:对2011-01-2012-03收治的23例老年肱骨近端骨折患者(均为单侧)行锁定接骨板治疗,其中男8例,女15例,年龄57~72(平均63.2)岁。术后通过ASES评分和Constant评分评估患者肩关节功能恢复情况。结果:23例患者均获得随访,随访时间12~16(平均13.6)个月。最后一次随访ASES评分和Constant评分,患者的平均得分分别为78.9分和77.2分。结论:锁定接骨板是治疗老年患者肱骨近端骨折的理想手术方式。     

新型内固定系统与锁定加压钢板系统治疗简单肱骨干骨折的对比分析

目的比较新型内固定系统桥接组合式内固定系统与锁定加压钢板治疗简单肱骨骨折的临床效果。方法 68例简单肱骨骨折患者按内固定方式不同分为桥接组合式内固定系统组(桥接组,37例)和锁定加压钢板组(锁定钢板组,31例)。记录手术时间、术中出血量、骨折愈合时间及相关并发症,肩关节Constant评分及肘关节Mayo评分。结果所有患者均获得随访,随访时间12~24个月(平均16.0个月)。两组在手术时间、术中出血量、肩肘关节功能评分上对比无统计学意义(P>0.05)。桥接组骨折愈合时间短于锁定钢板组,骨不连发生率低于锁定钢板组,差异有统计学意义(P<0.05)。两组均未出现桡神经损伤、伤口感染等并发症。结论新型内固定系统治疗肱骨干简单骨折,固定效果与锁定加压钢板组相似,但手术操作更方便,能减少对骨折端血供的破坏,利于骨折愈合。     

人工肱骨头置换术治疗老年肱骨近端骨折临床分析

目的 评价人工肱骨头置换术治疗老年肱骨近端骨折的效果。方法 肱骨近端粉碎性骨折老年患者72例,根据手术方法分为观察组36例和对照组36例,观察组行肱骨头置换术,对照组行锁定钢板内固定术,比较2组手术时间、术中出血量、术后引流量、住院时间和并发症发生情况,采用Constant-Murley评分系统对肩关节功能恢复情况进行评价。结果 观察组手术时间（（85.7±9.4）min）、术中出血量（（187.6±29.7）mL）、术后引流量（（60.5±6.4）mL）和住院时间（（10.3±2.1）d）与对照组（（103.1±11.2）min、（250.3±34.2）mL、（78.1±5.9）mL、（14.5±1.9）d）比较差异有统计学意义（P〈0.05）;术后3个月及1a观察组Constant-Murley评分（（61.3±4.7）、（67.4±3.4）分）高于对照组（（52.7±3.8）、（60.8±2.9）分）（P〈0.05）;观察组并发症发生率（11.1%）与对照组（16.7%）比较差异无统计学意义（P〉0.05）。结论肱骨头置换术治疗老年肱骨头近端粉碎性骨折疗效确切,与锁定钢板内固定术相比,具有手术时间短、术中出血量少、住院时间短及并发症发生率低等优点。     

锁定加压钢板内固定治疗肱骨近端骨折疗效分析

目的：探讨锁定加压钢板（LCP）治疗肱骨近端骨折的疗效。方法：对2004年1月-2009年12月就诊的肱骨近端骨折患者37例进行随访,年龄45～69岁,其中NeerⅡ型骨折试行手法复位失败3例,NeerⅢ型骨折23例,NeerⅣ型骨折11例。分别对术后8周骨折愈合率、术后肩关节功能恢复情况进行分析,肩关节功能评分分别按Neer评分及Constant Murley绝对值标准评分两种评分方法进行。结果：37例患者术后8周均达到临床愈合标准,愈合率100％。肩关节功能Neer评分结果：优25例,良10例,中1例,差1例,优良率94．6％。Constant—Murley绝对值评分结果：优24例,良10例,中2例,差1例,优良率91．9％。结论：应用LCP治疗NeerⅢ,Ⅳ型肱骨近端骨折,骨折愈合及肩关节功能恢复均良好,是临床上比较理想的治疗方法。