Objective: Anterolateral approaches for proximal humerus osteosynthesis have great advantages because they allow direct exposure of the lateral aspect of the humerus without the muscular retraction seen in the deltopectoral approach. However, much resistance is found among surgeons due to the potential risk of iatrogenic injury to the axillary nerve. To identify the incidence of axillary nerve iatrogenic lesions and evaluate the functional results of proximal humerus osteosynthesis with locking plates using anterolateral approaches. Methods: The literature review followed the PRISMA protocol. Results: A total of 23 articles were selected from 786 patients submitted to anterolateral approaches. Three cases (0.38%) of iatrogenic axillary nerve lesions were confirmed. The results of the functional tests were similar to those of the deltopectoral approach. Conclusion: Anterolateral approaches are a viable and safe alternative for proximal humerus osteosynthesis with locking plate. Subacromial impingement was the most frequent complication. Level of Evidence II, Systematic Review.
OBJECTIVES: To evaluate the outcomes in patients treated for humerus distal third fractures with MIPO technique and visualization of the radial nerve by an accessory approach, in those without radial palsy before surgery. METHODS: The patients were treated with MIPO technique. The visualization and isolation of the radial nerve was done by an approach between the brachialis and the brachiorradialis, with an oblique incision, in the lateral side of the arm. MEPS was used to evaluate the elbow function. RESULTS: Seven patients were evaluated with a mean age of 29.8 years old. The average follow up was 29.85 months. The radial neuropraxis after surgery occurred in three patients. The sensorial recovery occurred after 3.16 months on average and also of the motor function, after 5.33 months on average, in all patients. We achieved fracture consolidation in all patients (M=4.22 months). The averages for flexion-extension and prono-supination were 112.85° and 145°, respectively. The MEPS average score was 86.42. There was no case of infection. CONCLUSION: This approach allowed excluding a radial nerve interposition on site of the fracture and/or under the plate, showing a high level of consolidation of the fracture and a good evolution of the range of movement of the elbow. Level of Evidence IV, Case Series
Objective: To evaluate the results of displaced radial neck fractures in children trated surgically with flexible titanium intramedullary nails. Method: This is a retrospective study of five cases of radial neck fractures with displacement greater than 30° fixed with flexible intramedullary nails. Patients were evaluated regarding functional outcome through range of motion and the Mayo Elbow Performance Score (MEPS), as well as radiographic exams. Results: Five patients, with a mean age of 8.4 years were assessed, during a mean post-operative follow up of 12.2 months. Open reduction was necessary in three cases with major displacement. At the end of the follow up, 80% of the patients had excellent results, 20% good results, and all fractures healed. As complications we observed: heterotopic ossification, superficial infection and radial head necrosis. Conclusions: In spite of the small sample, our results with flexible titanium intramedullary nails were similar to the current literature, with good functional outcomes. Level of Evidence III, Retrospective Study.
OBJECTIVES: To evaluate the functional outcome of patients with surgically treated terrible triad of the elbow. METHODS: A retrospective evaluation was performed using the MEPS score (Mayo Elbow Performance Score) of patients diagnosed with terrible triad of the elbow who underwent surgical treatment. RESULTS: 14 patients (nine men and five women) and 15 elbows (one bilateral case) were evaluated. A MEPS average score of 78 points and 86% good and excellent results was obtained. As complications, we had one case of infection and three of neuropraxia of the ulnar nerve. CONCLUSION: The patients had stable elbow with good function, however with reduced range of motion. Level of Evidence IV, Case Series.
Objective: The main surgical approach in proximal humeral fractures is the deltopectoral approach. Many surgeons avoid the anterolateral approach, fearing its complications, especially axillary nerve injury. The objective of this study is to evaluate shoulder function and complications in patients with proximal humeral fractures treated using an anterolateral approach with direct observation of the axillary nerve. Methods: Retrospective study with postoperative radiological and functional evaluations (Constant and DASH scores) and review of the complications. The associations between fracture classification and the difference in Constant scores among the subjects and the final angle of consolidation were analyzed using Fisher's test or analysis of variance (ANOVA). The Constant scores were compared among the shoulders using the paired t-test. Results: The study evaluated 35 patients. Shoulder function was decreased, compared with the contralateral side (p<0.005). The only factor related to functional worsening was the Neer IV fracture. The main complication was malunion. There were no clinical changes related to the axillary nerve. Conclusion: The treatment using the extended anterolateral approach produced good functional results, although the function was decreased (Neer IV fractures). The main complication was malunion. There were no side effects due to exposure of the axillary nerve. Level of evidence III, Retrospective Study.
Introduction Fractures of the humeral shaft account for about 3% to 5% of all fractures. Although conservative treatment remains the first choice, there are a number of surgical indications. Minimally invasive plate osteosynthesis shows good functional results. However, complications have been reported, such as non-union. Objective To assess the prevalence and risk factors for non-union after treatment of humeral shaft fractures using minimally invasive plate osteosynthesis. Materials and methods This retrospective study was carried out in patients treated by minimally invasive plate osteosynthesis between 2009 and 2019. Demographic data and variables related to the fracture that could influence bone healing were analysed. The unpaired t-test and Mann–Whitney test were used for the statistical analyses. Categorical variables were analysed using the chi-square test or Fisher's exact test Results The study population showed a male predominance (53 of 75, 70.7%). The average time for fracture healing was 19.8 ± 15.3 weeks. Seven patients developed non-union. Only the presence of an open fracture increased the likelihood of non-union. Conclusions The prevalence of non-union in patients treated by minimally invasive plate osteosynthesis was 9.3%. Patients with open fractures were six times more likely to progress to non-union. Fracture characteristics (Arbeitsgemeinschaft für Osteosynthesefragen classification, fracture location and plate working length) did not influence progression to non-union.
Background: Proximal humeral fractures can progress to osteonecrosis of the humeral head. Hertel developed a binary classification system (12 subtypes) and demonstrated that pattern types 2, 9, 10, 11, and 12, or fracture extension of the posteromedial head less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, are at greater risk for osteonecrosis. Few studies have evaluated the incidence of osteonecrosis after proximal humerus fractures were treated using osteosynthesis through the anterolateral approach. The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk for developing osteonecrosis and its incidence after osteosynthesis using the anterolateral approach. Methods: This was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach. Patients were divided into two groups: high risk for necrosis (group 1) and low risk for necrosis (group 2) according to Hertel’s criteria. The overall prevalence of osteonecrosis and the prevalences in each group were calculated. A radiological examination was performed in the anteroposterior, scapular, and axillary views, before and after the operation (minimum 1 year after surgery). The groups were compared using the Chi-square test or Fisher’s exact test. The unpaired t-test (parametric variables) and the Mann-Whitney test (non-parametric) were used. Results: In total, 39 patients were evaluated. The postoperative follow-up time was 14.5 ± 3.3 months. Time to onset of necrosis was 14.1 ± 3.9 months. Sex, age, and time between trauma and surgery did not influence the risk of necrosis. Type 2, 9, 10, 11, and 12, or fractures with posteromedial head extension less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, as well as grouping did not influence the risk for osteonecrosis. Conclusions: Hertel’s criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach. The total prevalence of osteonecrosis was 17.9%.
Mortality of patients after osteosynthesis of proximal humeral fractures (PHF) has been poorly studied in contrast to fractures of the proximal femur. Objective: To evaluate the mortality of older patients with PHF undergoing surgical treatment. Methods: Retrospective study of patients undergoing surgical treatment PHF between 2009-2019. Demographic data, Neer classification, and mortality of this cohort of patients were evaluated. Non-categorical variables were tested using the Kolmogorov-Smirnov test. The unpaired t-test (parametric variables) was used. Categorical variables were tested by Fisher’s exact test. A Kaplan-Meier mortality curve was constructed. Results: 59 patients were evaluated. There was a predominance of females in the sixth decade of life. The most prevalent fractures were Neer’s type III. The highest mortality occurred in the first 4 years after surgery (4.1 + 3.2 years). The only comorbidity capable of changing the survival curve was DM (p = 0.03) Conclusion: Overall mortality was 11.3%. The highest mortality occurred in the first 4 years of follow-up. Diabetic patients evolve with earlier mortality and have 7 times more chance of death. Level of Evidence III, Retrospective Study.
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