A New Locking Plate for Unstable Fractures of the Proximal Humerus

Background Proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. Questions/purposes In this prospective randomized study, we aimed to investigate whether the deltoid-split approach is superior to the deltopectoral approach with regard to (1) complication rate; (2) shoulder function (Constant score); and (3) pain (visual analog scale [VAS]) for internal fixation of displaced humeral fractures with a polyaxial locking plate.Methods We randomized 120 patients with proximal humeral fractures to receive one of these two approaches (60 patients for each approach). We prospectively documented demographic and perioperative data (sex, age, fracture type, hospital stay, operation time, and fluoroscopy time) as well as complications. Followup examinations were conducted at 6 weeks, 6 months, and 12 months postoperatively, including radiological and clinical evaluations (Constant score, activities of daily living, and pain [VAS]). Baseline and perioperative data were comparable for both approaches. The sample size was chosen to provide 80% power, but it reached only 68% as a result of the loss of followups to detect a 10-point difference on the Constant score, which we considered the minimum clinically important difference. Results Complications or reoperations between the approaches were not different. Eight patients in the deltoid-split group (14%) needed surgical revisions compared with seven patients in the deltopectoral group (13%; p = 1.00). Deltoid-split and deltopectoral approaches showed similar Constant scores 12 months postoperatively (Deltoid-split 81; 95% confidence interval [CI], 74-87 versus deltopectoral 73; 95% CI, 64-81; p = 0.13), and there were no differences between the groups in terms of pain at 1 year (deltoid-split 1.8; 95% CI, 1.2-1.4 versus deltopectoral 2.5; 95% CI, 1.7-3.2; p = 0.14). No learning-curve effects were noted; fluoroscopy use during surgery and function and pain scores during followups were similar among the first 30 patients and the next 30 patients treated in each group. Conclusions The treatment of proximal humeral fractures with a polyaxial locking plate is reliable using both approaches. For a definitive recommendation for one of these approaches, further studies with appropriate sample size are necessary.

Section: Discussionmentioning

confidence: 50%

Deltoid-split or Deltopectoral Approaches for the Treatment of Displaced Proximal Humeral Fractures?

Buecking

Mohr

Bockmann

et al. 2014

“…Only one of our patients (treated operatively) developed osteonecrosis (2%). There has been a variable incidence of osteonecrosis cited in the literature from 4% to 16% [3,8,14,22]. These results provide useful information for surgeons who treat these fractures as they counsel patients with regard to expected outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Intra-articular screw perforation was our most prevalent complication, and it can arise because of improper hardware placement due to poor intraoperative imaging, screw migration/ implant shifting, or collapse of the subchondral bone onto the stationary hardware [9]. The incidence of this complication is well documented in the current literature and ranges from 5% to 23% [8,9,14,18,21]. This complication can cause substantial injury to the glenohumeral joint, require reoperation, and lead to permanent loss of joint function [29].…”

Section: Discussionmentioning

confidence: 99%

Three- and Four-part Fractures Have Poorer Function Than One-part Proximal Humerus Fractures

Ong

Bechtel

Walsh

et al. 2011

Background Locking plates have become a commonly used fixation device in the operative treatment of three-and four-part proximal humerus fractures. Examining function in patients treated nonoperatively and operatively should help determine whether and when surgery is appropriate in these difficult-to-treat fractures. Questions/purposes We compared functional scores, ROM, and radiographs in patients with one-part proximal humerus fractures treated nonoperatively to those in patients with displaced three-and four-part proximal humerus fractures treated with open reduction and internal fixation using locking plates. Patients and Methods We retrospectively reviewed 142 patients with proximal humerus fractures treated with a standardized treatment algorithm over a 6-year period.

“…Inclusion criteria included all patients 18 years of age or older with a displaced fracture or fracture-dislocation of the proximal humerus as defined by previously defined criteria [2,5,8,13,14,25,26]. We excluded patients with preexisting nerve deficits before their current proximal humerus fracture.…”

Section: Methodsmentioning

confidence: 99%

Nerve Monitoring During Proximal Humeral Fracture Fixation: What Have We Learned?

Warrender

Oppenheimer

Abboud

2011

Background The incidence of neurologic injury after proximal humerus fractures is variable, ranging from 6.2% to as much as 67%. However, it is unclear what factors might contribute to these injuries or whether they can be prevented by intraoperative nerve monitoring. Questions/purposes Therefore, using intraoperative nerve monitoring, we assessed the incidence, pattern of nerve involvement, and predisposing factors for nerve injury before and during shoulder fracture fixation. Patients and Methods We used continuous intraoperative monitoring of the brachial plexus in 37 patients undergoing open operative treatment of proximal humerus fractures. Impending intraoperative compromise of nerve function was signaled by sustained neurotonic EMG activity or greater than 50% amplitude attenuation of transcranial electrical motor evoked potentials (MEPs) (or both). When a nerve alert occurred, current surgical activity and arm and retractor position were recorded and adjustments were made to relieve tension.