Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

Objective

The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures.

Design

A retrospective clinical trial.

Setting

Department of Orthopaedics, Tianjin Medical University General Hospital.

Patients

Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates.

Intervention

The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied.

Main outcome measurements

Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed.

Results

After average 26.7 months, the average Constant Score was 72.6 ± 13.2 points and the average VAS was 1.2 ± 0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8 %).

Conclusions

The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.     

Treatment of Two-Part Proximal Humerus Fractures: Intramedullary Nail Compared to Locked Plating

Background

Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate.

Purpose

The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN.

Methods

A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function.

Results

Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124° and 120° in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134° of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant.

Conclusions

Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.     

Treatment for displaced proximal humerus fractures: comparison of interlocking plate fixation versus minimal invasive techniques

Background and purpose

The functional results and the complications following interlocking plate fixation of displaced proximal humerus fractures should be evaluated and compared with those following minimal invasive fixation techniques.

Patients and methods

Fifty patients (30 women, 20 men, mean age 62.7 (18–91) years) were treated for a displaced proximal humerus fracture using an interlocking plate fixation (PHILOS^®) between 2003 and 2004. The mean follow-up time was 12 (9–36) months. Functional and radiographic results (Constant-Murley and Neer scores) were analyzed and compared with an equivalent historical control group of 53 patients operated for the same fracture types using minimal invasive techniques (K-wires and/or cannulated screws) between 1995 and 1997. According to the OTA/AO classification, there were 15 type A, 18 type B, and 17 type C fractures in the plate fixation group, and 23, 25, and 5 of these types in the control group, respectively.

Results

The mean Neer score was 85.9, the mean Constant-Murley score 84, whereas 82.4 and 75.4 for the control group, respectively. Good and excellent results were seen in 78 %, whereas in 70 % in the control group. The results were dependent upon the fracture’s type, sex, and patient’s age. Complications were seen in 9 patients, whereas in 16 patients in the control group.

Interpretation

Using an interlocking plate, the indication of fixation of displaced proximal humerus fractures had been expanded to type C fractures. The implant failure rate can be reduced. The functional results achieved are better compared with those following minimal invasive techniques.     

Biomechanische Untersuchung der winkelstabilen Plattenosteosynthese am proximalen Humerus

Introduction

Proximal humeral fractures are common in the elderly population and are often associated with osteoporosis. Fixation of unstable proximal humeral fractures is problematic due to loss of fixation in osteoporotic bone. Fixed-angle devices are intended to provide superior mechanical stability due to the principle of an internal fixator. The NCB®-PH (non-contact-bridging proximal humerus) plate is a new fixed-angle device that locks the screws to the plate by secondary insertion of a locking cap. The aim of this study was to investigate if and to what extent NCB-PH plates applied in the locked mode provide higher mechanical stability in a proximal humerus fracture model.

Methods

For this investigation 16 (8 pairs) fresh frozen cadaveric humeri were used. An AO/ASIF 11-B 1 fracture of the proximal humerus was created in each bone and fixed with the NCB-PH plate. In a paired setting one bone was fixed with the plate in the locked mode and the other with the plate in the non-locked mode. The bones were then subjected to 100 cycles of axial loading and interfragmentary motion was measured. Bones surviving this test were subjected to load-to-failure testing and the force at which failure occurred was recorded.

Results

Bones fixed with the plate in the locked mode showed a statistically significant lower (51%) interfragmentary rotation compared to bones fixed with the plate in the non-locked mode. There was also a tendency for the bones fixed with the plate in the locked mode to fail first under higher forces (16%) during load-to-failure testing.

Conclusion

The NCB-PH plate provides superior interfragmentary stability when used in the locked mode in a human cadaveric proximal humerus fracture model. Therefore, we recommend that all screws should be inserted in the locked mode. The results suggest that the NCB-PH plate in the locked mode provides higher primary postoperative stability thus permitting early functional treatment of the patient.     

Posterior fixation of type IV humeral capitellum fractures with fully threaded screws in adolescents

Purpose

Humeral capitellum fractures comprise approximately 1% of all elbow fractures. In this study, we examined the clinical, radiographic, and functional outcomes following operative stabilization of Bryan and Morrey type IV fractures of the capitellum in adolescents. We applied headless cannulated screws in a posteroanterior direction without damaging the articular cartilage surface of the fractures.

Methods

Eight adolescent patients (six male, two female) with a mean age of 15 ± 2.1 years (range 13–18 years) were treated for type IV (McKee) humerus capitellum fractures. In the preoperative radiological evaluation, anteroposterior and lateral radiographs and computed tomography (CT) images were performed. A lateral surgical approach was used, and cannulated fully threaded headless screws were applied in a posteroanterior direction as fixation materials in the fracture reduction. The Mayo Elbow Performance Score was used in the evaluation of elbow joint functions.

Results

Patients were followed up for a mean of 24.6 months. Fracture union was achieved at a mean of 5 ± 0.92 weeks (range 4–6 weeks). The mean elbow extension flexion arc was 135° ± 13.47° (range 110°–150º) and the mean pronation supination arc was 156° ± 4.43° (150°–160°). In one patient, there was nonconformity in the humerus trochlea and in another patient, there was keloid formation on the surgical scar. All patients attained excellent results according to the Mayo Elbow Performance Score.

Conclusions

In the treatment of type IV capitellum fractures in adolescents, open reduction with a lateral surgical approach and fixation using posteroanterior directed, cannulated, fully threaded, headless screws is a reliable method to achieve a pain-free functional elbow joint.     

Der Anbindungsschlauch zur Weichteilrekonstruktion nach Megaprothesenimplantation

Objective

To restore function and an active range of motion, and stabilize the joint after joint resection.

Indications

Restoration of a joint capsule following reconstruction of a defect using a proximal humerus and femur prosthesis. Reattachment of tendons and muscles.

Contraindications

Acute or chronic infection. Status after cured infection.

Surgical technique

The attachment tube (Implantcast, Buxtehude, Germany) is attached to the joint capsule (proximal humerus and femur replacement) or directly to the prosthesis (for proximal tibial replacements) using nonresorbable Ethibond? sutures (Johnson &; Johnson Medical, Norderstedt, Germany). Bone anchors are used, if the joint capsule has been completely resected. The body of the prosthesis, which has previously been attached to the shaft, is then pulled distally through the tube, and a (bipolar) head or humerus cap is placed on top of it. In the proximal humerus and femur replacement, proximal slitting of the tube may be helpful to reposition the prosthesis under vision. Following repositioning, fixation of the tube is completed ventrally and the slits previously made in the tube are sutured. Fixation of the tube to the prosthesis is carried out either with Ethibond? sutures placed around the tube, or??for a proximal humerus and tibia replacement??it is possible to attach suture material to the prosthesis through eyelets.

Postoperative management

Further treatment basically depends on the location of the mega-endoprosthesis used.

Results

Macroscopically and microscopically, fibroblasts migrate into the tube??s mesh, so that attachment of the soft tissue takes place. As of yet, no cases of luxation have occurred when the tube is used in combination with a bipolar head, and with fixed-implant cups the risk of luxation can be reduced using tripolar cup systems. In patients with a proximal tibial replacement, active straightening of the knee joint can be restored in most cases, although some limitation on active extension is still possible depending on the extent of the tumor resection.     

Der gestielte Pectoralis-major-Lappen zur Behandlung der eitrigen Arthritis des Sternoklavikulargelenks

Objective

Closure of the wound defect with a pedicled pectoralis major muscular flap after successful surgical treatment of septic arthritis of the sternoclavicular joint (SCJ).

Indications

Defect of the thoracic wall after septic arthritis of the SCJ.

Contraindications

Persistent infection of bony or soft tissue structures; persistent septicemia; persistent mediastinitis.

Surgical technique

After successful treatment of the local infection and radical debridement of the wound, the incision is expanded parallel to the clavicle and to the sternum. The neurovascular pedicled pectoralis flap is mobilized and a resection of the muscular attachment at the humerus is performed. Finally, the flap is rotated at the pedicle and attached to the defect zone.

Postoperative management

Anticoagulation with low molecular weight heparin and possibly aspirin (100 mg/day); short-term immobilization of the involved upper extremity. Avoidance of major weight bearing for a period of 6 weeks.

Results

Over a period of 4 years, 18 patients suffering from septic arthritis of the SCJ underwent surgical treatment. Of these, 9 patients were treated with pedicled muscular flap. In all patients, uneventful wound healing was observed with no further revision operations being required. The functional and optical results were satisfactory.     

Surgical treatment of lateral Hoffa fracture with a locking plate through the lateral approach

Objectives

The goal of this study is to determine the efficacy of the surgical treatment of lateral Hoffa fracture with a locking plate and cannulated or lag screws through the lateral approach.

Materials and methods

A total of 12 isolated lateral Hoffa fractures were identified during the study period (February 2005 to February 2010). All fractures were treated by open reduction through the lateral approach. Internal fixation was performed with a contoured locking plate and cannulated or lag screws introduced from the non-weight-bearing area of the cartilage surface of the lateral femoral condyle. Radiological and functional outcome analysis was performed using Knee Society scores.

Results

Bony union of Hoffa fracture was achieved in all patients. The articular surface of lateral femoral condyle was anatomically reduced. There was no loss of reduction and fixation. Functional outcome of knee measurements showed a continuous significant improvement over the follow-up period.

Conclusion

Fixation with a locking plate and cannulated or lag screws for lateral Hoffa fracture seemed to be effective and reliable. The lateral approach had advantages for reduction and fixation of lateral Hoffa fracture during operation.     

Treatment of periprosthetic tibial plateau fractures in unicompartmental knee arthroplasty: plates versus cannulated screws

Introduction

Periprosthetic tibial plateau fractures (TPF) are rare but represent a serious complication in unicompartmental knee arthroplasty. The most common treatment for these fractures is osteosynthesis with cannulated screws or plates. The aim of this study was to evaluate two different treatment options for periprosthetic fractures. The hypothesis was that angle-stable plates show significantly higher fracture loads than fixation with cannulated screws.

Materials and methods

Twelve matched, paired fresh-frozen tibiae with periprosthetic TPF were used for this study. In Group A, osteosyntheses with cannulated screws were performed, whereas in Group B plates fixated the periprosthetic fracture. DEXA bone density measurement and standard X-rays (AP and lateral) were performed before loading the tibiae under standardised conditions with a maximum load of up to 10.0 kN. After the specimens had been loaded, fracture patterns and fracture loads were analysed and correlated with BMD, BMI, bodyweight (BW), age and size of the tibial implant.

Results

In the plate group all tibiae fracture occured with a median load of F _max = 2.64 (0.45–5.68) kN, whereas in the group with cannulated screws fractures occurred at a mean load of F _max = 1.50 (0.27–3.51) kN. The difference was statistically significant at p < 0.05.

Discussion

Angle-stable plates showed significantly higher fracture loads than fixation with cannulated screws. Cannulated screws show a reduced stability of the tibial plateau. Therefore in periprosthetic TPF, osteosyntheses with angle-stable plates should be recommended instead of cannulated screws.     

The measurement of bone mineral density of bilateral proximal humeri using DXA in patients with unilateral rotator cuff tear

Summary

We propose that the measurement of the bone mineral density (BMD) of the proximal humerus be standardized using the dual energy X-ray absorptiometry (DXA) in patients supposed to undergo rotator cuff repair surgery as well as those with the fracture of the proximal humerus as the BMD of the proximal humerus is decreased in these patients.

Introduction

We propose that the measurement of the BMD of the proximal humerus be standardized using the DXA in patients who are supposed to undergo rotator cuff repair surgery as well as those with the fracture of the proximal humerus.

Methods

We conducted the prospective study in 213 patients with unilateral rotator cuff tear but without contralateral shoulder pain or disease. In these patients, we preoperatively measured the BMD of the bilateral proximal humeri with a repeat measurement in 20 patients. We predefined three regions of interest (ROIs) in the proximal humerus with the consideration of the rotator cuff repair surgery as well as proximal humeral fractures.

Results

The measurement of the BMD of the proximal humerus using the DXA showed excellent reliability (intraclass correlation coefficient?>?.90). BMD values of all three ROIs in the affected shoulder were significantly lower than those in asymptomatic shoulder (all p?p?Conclusions It is imperative that the bone quality of the proximal humerus be accurately evaluated prior to surgery in patients who are supposed to undergo rotator cuff repair using suture anchors as well as in those with proximal humeral fractures. This is because the BMD of the proximal humerus is decreased in these patients.     

Suture fixation versus cable cerclage of the tuberosities in shoulder arthroplasty-clinical and radiologic results

Background

The most important individual parameter linked to functional outcome following hemiarthroplasty for fractures of the proximal humerus is anatomical healing of the tuberosities. The aim of our study was to evaluate whether the fixation method influences tuberosity healing and functional outcome.

Methods

Twenty-five consecutive patients with acute 4-part fractures of the proximal humerus were treated with hemiarthroplasty and cable fixation of the tuberosities. Twenty-nine previous patients with four-part fractures treated with hemiarthroplasty and suture fixation of the tuberosities were included as a control group. Functional evaluation was measured with the Constant Score 1?year after the operation. Radiographic evaluation included evaluation of the extent of tuberosity healing and head centralisation.

Results

The average Constant Score was 53.2 points in the suture group and 60.9 in the cable group (p?=?0.29). An x-ray evaluation revealed that 40% of the tuberosities in the suture group were anatomically healed versus 75% (p?=?0.027) in the cable group. In the suture group, 44% of the prostheses showed marked superior migration, whereas 25% of the prostheses in the cable group showed such migration (p?=?0.027).

Conclusion

In our collective adding an encircling steel cable for the fixation of the tuberosities resulted in higher anatomical healing rates.     

Treatment of unicameral bone cyst: systematic review and meta analysis

Purpose

Different treatment modalities have been utilized to treat unicameral bone cyst (UBC), but evidence has not been fully described to support one treatment over another and the optimal treatment is controversial. The aim of this quantitative systematic review was to assess the effectiveness of different UBC treatment modalities.

Methods

We utilized Pubmed to isolate retrospective studies on patients with UBC who received any kind of treatment. The included studies needed to have a minimum sample size of 15 patients, and have provided data on radiographic healing outcome.

Results

Sixty-two articles were selected for the meta-analysis from a total of 463 articles. The cumulative sample size was 3,211 patients with 3,217 UBC, and male to female ratio was 2.2:1. The summary or pool estimate of methylprednisolone acetate (MPA) injection resulted in a healing rate of (77.4 %) that was comparable to bone marrow injection (77.9 %). A higher healing rate was observed with MPA injection when inner wall disruption was performed. The pool estimate of bone marrow with demineralized bone matrix injection was high (98.7 %). UBC healing rate after surgical curettage was comparable whether autograft or allograft was utilized (90 %). UBC treatment with flexible intramedullary nails without curettage provided almost 100% healing rate, while continuous decompression with cannulated screws provided 89 % healing rate. Conservative treatment indicated a healing rate of 64.2, 95 % CI (26.7–101.8).

Conclusions

Active treatment for UBC provided variable healing rates and the outcomes were favorable relative to conservative treatment. Due to the heterogeneity of the studies and reporting bias, the interpretation of these findings should be handled with caution.     

Coronal plane fractures of the distal humerus involving the capitellum and trochlea treated with open reduction internal fixation

Introduction

Coronal plane fractures of the distal humerus involving the capitellum and trochlea are rare. Treatments have evolved from closed reduction to open reduction and internal fixation (ORIF) to achieve a stable joint that allows early mobilization.

Background

We determined the functional outcomes of treating coronal plane fractures of the distal humerus with ORIF.

Methods

We reviewed the records of all patients with coronal plane fractures of the distal humerus treated by ORIF. Fractures were classified according to Bryan and Morrey. Cannulated screws were used for fixation. All patients were evaluated using the Mayo Elbow Score Performance Index (MEPI) and disabilities of the arm, shoulder, and hand (DASH) scores at least 1 year later.

Results

Of the 18 patients evaluated (12 women), the mean (SD) age was 45.3(16.5) years (range 16–70). There were seven Type-I, five Type-III, and six Type-IV fractures. Mean follow-up was 43.6 (38.1) months (range 12–120). The mean elbow range of motion in sagittal plane at last follow-up ranged from 8.9° to 132.8°. The mean MEPI score was 86.7 (15.2) points (range 60–100), corresponding to 12 excellent, 2 good, and 4 fair outcomes. The mean DASH score was 15.3 (13.5) points (range 17–35.8). Heterotrophic ossification developed in one patient with delayed fixation; 14 patients with excellent or good results returned to their previous activity levels. Functional scores did not differ by age, sex, or fracture types (P > 0.05 for all comparisons).

Conclusion

ORIF with cannulated screws, which maintain a stable anatomic articular position, provides satisfactory results in coronal plane fractures of the distal humerus.

Level of evidence

Level IV case series.     

Sonographische Diagnostik der subkapitalen Humerusfraktur im Wachstumsalter

Aim of the study

The exact determination of the extent of deformities in juvenile proximal humerus fractures is difficult with plain x-rays. The aim of this study was to find out whether proximal humerus fractures can be diagnosed and the extent of the deformity can be detected by ultrasonography.

Patients and methods

In a prospective, multicentre trial children aged 0–12 years with suspected proximal humerus fractures were examined. Initially a standardized sonographic evaluation was performed and the extent and the direction of the deformity were determined. The recommended treatment was noted. Afterwards standard x-rays were taken and the results of both diagnostic procedures were compared.

Results

A total of 33 children were examined, 14 male and 19 female, with a mean age of 7.6 years. In the ultrasound examination 17 out of 18 proximal humerus fractures were detected. In comparison to x-ray diagnostics ultrasonography proved to have a sensitivity of 94% and a specificity of 100%. In 16 cases ultrasonography gave a better result than x-ray imaging and x-ray was better in 5 cases.

Conclusion

Ultrasonography is suitable for detection and exclusion of fractures and better than x-ray diagnosis for evaluation of the type and direction of deformations of proximal humerus fractures.     

Age-related changes in proximal humerus bone health in healthy, white males

Summary

The proximal humerus is a common site for osteoporotic fracture. The current study demonstrates the rate of age-related decline in proximal humerus bone health. The data suggest aging is associated with considerable loss of bone mass, structural deterioration and reduced bone strength at the proximal humerus.

Introduction

The proximal humerus is relatively under investigated despite being the fourth most common site for osteoporotic fracture.

Methods

A cross-sectional study was performed to assess age-related changes in dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) properties of the proximal humerus in a cohort of 170 healthy, white males.

Results

Regression models estimated considerable age-related loss of DXA measured bone quantity at the proximal humerus, with areal bone mineral density modeled to decline by 29% (95% confidence interval [CI], 17.5–35.0%) in the 50?years between ages 30 and 80?years (p?<?0.001). pQCT measures indicated aging was associated with progressive periosteal and endosteal expansion, with the later occurring more rapidly as indicated by age-related declines in cortical bone mass, area and thickness (all p?<?0.01). The net result of the density, mass and structural changes was a 26% (95% CI, 13.5–38.0%) decline in pQCT estimated proximal humerus bone strength in the 50?years between ages 30 and 80?years (p?<?0.001).

Conclusion

Aging is associated with considerable declines in proximal humeral bone health which, when coupled with a traumatic event such as a fall, may contribute to osteoporotic fracture at this site.     

Behandlungsalgorithmus der Kahnbeinpseudarthrose

Introduction

We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed.

Materials and methods

Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans.

Results

Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53).

Conclusion

Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.     

Augmentierte Osteosynthesen am Beispiel des proximalen Humerus und Femurs

Background

The treatment of osteoporotic fractures is still a challenge. The biomechanical advantages of augmentation with respect to primary in vitro stability in the proximal humerus and the clinical use of cement augmented osteosynthesis in the proximal femur are shown in this article.

Material and methods

In this study six paired human humeri were randomized in an augmented and a non-augmented group. Osteosynthesis was performed with a PHILOS plate (PHILOS, proximal humeral internal locking system, Synthes). In the augmented group the two screws purchasing in the weakest cancellous bone were augmented. The specimens were tested in a three part fracture model in a varus bending test. Regarding the proximal femur the application of the augmented PFNA (proximal femoral nail antirotation, Synthes) was prospectively registered in 40 patients and follow-up was performed at 3 and 12 months.

Results

The augmented PHILOS plates withstood significantly more load cycles until mechanical failure occurred. The correlation to bone mineral density (BMD) showed that augmentation could compensate for low BMD. A total of 38 patients were treated primarily with the augmented PFNA (mean age 87?±?5 years) and in the remaining 2 patients this was carried out as a secondary revision (mean age 54?±?5 years). No mechanical complications were seen in the follow-up period. Cement leakage into the joint was not observed.

Conclusion

The augmentation of the screws in locked plating in a proximal humeral fracture model is effective in improving the primary stability in a cyclic varus bending test. The targeted augmentation of two particular screws in a region of low bone quality within the humeral head was almost as effective as four screws with twice the amount of bone cement. Screw augmentation combined with knowledge of the local bone quality could be more effective in enhancing the primary stability of a proximal humeral locking plate because the effect of augmentation can be exploited more effectively limiting it to the degree required. The augmented PFNA is a safe and easy to use device to treat osteoporotic proximal femoral fractures. The overall advantage has yet to be shown in further studies covering more patients.