ObjectiveTo investigate the effectiveness of limited open reduction via “door-shaft method” and internal fixation with locking plate for two- and three-part fractures of the proximal humerus.MethodsThe clinical data of 64 patients with proximal humeral fractures who were admitted between January 2013 and December 2016 and met the selection criteria were retrospectively analyzed. There were 23 males and 41 females, with an average age of 68.0 years (range, 50-89 years). The injuries were caused by falling in 57 cases, traffic accident in 5 cases, and falling from height in 2 cases. The interval between injury and operation was 1-7 days (mean, 2.1 days). According to Neer classification, there were 28 cases of two-part fractures and 36 cases of three-part fractures. According to the angulation direction of the proximal humeral neck shaft angle, there were 21 cases of adduction fractures and 43 cases of abduction fractures. The fractures were treated with limited open reduction via “door-shaft method” and proximal humerus internal locking systems for internal fixation. The operation time, intraoperative blood loss, number of fluoroscopy, hospital stay, and complications were recorded. The fracture healing was reviewed by X-ray film and the healing time was recorded. The shoulder joint function was evaluated by Neer score standard.ResultsThe operation time was 45-127 minutes, with an average of 82.3 minutes. The intraoperative blood loss was 30-125 mL, with an average of 62.7 mL. Intraoperative fluoroscopy was performed 30-69 times, with an average of 37.0 times. The hospital stay was 6-23 days, with an average of 10.3 days. All incisions healed by first intention. All patients were followed up 12-37 months, with an average of 18.3 months. X-ray film re-examination showed that all fractures healed, the healing time was 12-21 weeks, with an average of 14.3 weeks. After operation, 3 cases had shoulder stiffness and 1 case had fracture malunion. At last follow-up, the Neer score of shoulder joint function was 49-97, with an average of 83.1. Among them, 38 cases were excellent, 13 cases were good, 10 cases were fair, and 3 cases were poor. The excellent and good rate was 79.7%. The excellent and good rate of patients with two-part fractures was 82.1% (23/28), and the excellent and good rate of patients with three-part fractures was 77.8% (28/36).ConclusionThe “door-shaft method” not only reduces the difficulty of the Joystick technique in the reduction of proximal humerus fractures, but also provides auxiliary stability. It is used for limited open reduction and internal fixation with locking plate to treat the two- and three-part fractures of the proximal humerus, which can achieve good effectiveness.
Objective
To evaluate the effectiveness of locking plates for Neer 3- and 4-part proximal humerus fractures.
Methods
A retrospective analysis was made on the clinical data of 77 patients with 3- or 4-part proximal humerus fractures, who underwent open reduction and internal fixation of locking plates and were followed up more than 12 months between July 2008 and May 2011. There were 39 males and 38 females with an average age of 54.2 years (range, 18-81 years). Fractures were caused by falling in 47 cases, by traffic accident in 16 cases, by falling from height in 4 cases, by sporting in 5 cases, and by other reasons in 5 cases. The time between injury and operation was 2-16 days (mean, 4.5 days). According to Neer classification, there were 54 cases of 3-part fracture and 23 cases of 4-part fracture. The Constant scores, visual analogue score (VAS), and the complications were evaluated during follow-up.
Results
After operation, healing of incisions by first intention was obtained in 76 cases and healing by second intention in 1 case. All patients were followed up 12-36 months (mean, 18.5 months). At last follow-up, the Constant score was 71.1 ± 11.9; the results were excellent in 18 cases, good in 24 cases, fair in 25 cases, and poor in 10 cases with an excellent and good rate of 54.5%. The VAS score was 2.8 ± 2.2. Bone nonunion occurred in 2 cases; the other patients had bone union within 2-6 months (mean, 3.2 months). The complications occurred in 25 cases (32.5%). Revision surgery was performed in 15 patients (19.5%).
Conclusion
The treatment of Neer 3- and 4-part proximal humerus fractures remains challenging. Anatomic reduction, stable fixation, and reduced humeral head blood supply disruption may lead to a satisfactory outcome.
Objective To compare the efficacy and indication of the three different surgical methods in the treatment of the senile osteoporotic comminuted proximal humerus fracture. Methods From January 2006 to April 2008, 70 senile patients with osteoporotic comminuted proximal humerus fracture were randomly divided into three groups to receive different surgical methods. There were 21 patients in the group A receiving Kirschner tension band or screw internal fixation, 37 patients in group B receiving internal fixation of locking proximal humeral plate, and 12 patients in group C receiving humeral head replacement. There were 36 males and 34 females aged 53-76 years old (average 61.9 years old). All the fractureswere closed, osteoporotic, and III and IV-part according to Neer classification. The disease course was 1-8 days (average 2.8 days). There was no significant difference among three groups in terms of basel ine information (P gt; 0.05). The effective antiosteoporosis therapy was given during perioperative period. Results All the incision healed by first intention. All patients reached anatomical or almost anatomical reduction without compl ications such as postoperative infection, neurovascular injury, and nonunion of bone. Seventy patients were followed up for 9-20 months (average 11.5 months). The heal ing time of the fracture was 8-12 weeks in group A and group B, the average heal ing time was 10.5 weeks in group A and 10 weeks in group B, and there was no significant difference between two groups (P gt; 0.05). Group C presented with no sign of prosthesis loosening or shoulder dislocation. Six cases in group A suffered from frozen shoulder, pain or acromion impingement syndrome 6 months after operation and obtained various degrees of improvement via functional exercises. One of them had humeral head avascular necrosis 12 months later and achieved fair recovery after performing humeral head replacement. Two cases in group B had frozen and painful shoulder 6 months after operation and achieved fair recovery after functional exercises. One cases in group C had frozen shoulder and poor performance of abduction and upl ifting and achieved improvement after exercises. The rest patients achieved satisfactory curative effects. The incidence of compl ication was 28.6% in group A, 5.4% in group B, and 8.3% in group C. The incidence of complication in group A was significantly higher than that of group B and group C (P lt; 0.05), and there was no significant difference between group B and group C (P gt; 0.05). Neer scale system was adopted to evaluate the postoperative shoulder function, the excellent and good rate was 66.7% in group A, 78.4% in group B, and 83.3% in group C. The excellent and good rate in group A was significantly less than that of group B and group C (P lt; 0.05), and there was no significant difference between group B and group C (P gt; 0.05). Conclusion The senile osteoporotic comminuted proximal humerus fracture treated by surgery can obtain satisfied results. Most patients can use locking plate fixation. Those with poor general condition can use Kirschner wire fixation with tension band or screws, but this method is subject to certain constraints. For some elder patients with humeral head necrosis and humeral head crushed, priority should be given to the use of humeral head replacement.
Open reduction and internal fixation with plate and screw is one of the most widely used surgical methods in the treatment of proximal humeral fractures in the elderly. In recent years, more and more studies have shown that it is very important to strengthen the medial column support of the proximal humerus during the surgery. At present, orthopedists often use bone graft, bone cement, medial support screw and medial support plate to strengthen the support of the medial column of the proximal humerus when applying open reduction and internal fixation with plate and screw to treat proximal humeral fractures. Therefore, the methods of strengthening medial column support for proximal humerus fractures and their effects on maintaining fracture reduction, reducing postoperative complications and improving functional activities of shoulder joints after operation are reviewed in this paper. It aims to provide a certain reference for the individualized selection of medial support methods according to the fracture situation in the treatment of proximal humeral fractures.
ObjectiveTo investigate the clinical results of locking-plate with an intramedullary fibular allograft for type C2 proximal humeral fracture fixation.
MethodsBetween January 2011 and August 2012, 16 patients with proximal humeral fractures (AO type C2) were treated by locking-plate with an intramedullary fibular allograft. The clinical data were retrospectively analysed. There were 5 males and 11 females with an average age of 64 years (range, 55-70 years). The injury causes were falling injury in 12 cases, traffic accident injury in 3 cases, and sports injury in 1 case. The duration between injury and operation ranged from 2 to 6 days (mean, 4.5 days). The imaging data were used to judge the fracture healing, and to measure the neck-shaft angle and the height of humeral head; the disability of arm, shoulder, and hand (DASH) score, short-form 36 health survey scale (SF-36), and Neer score were used to evaluate the function of the shoulder after surgery.
ResultsPrimary healing of incision was obtained in all patients; no complication of vascular and nerve injury occurred. Sixteen cases were followed up 12-24 months (mean, 18 months). All fractures healed at 18-24 weeks (mean, 20 weeks). No complication occurred as follows:re-displacement, necrosis, rejection reaction, and loosening or extraction of screws. At last follow-up, the neck-shaft angle was 126.6-136.9° (mean, 132.5°), showing a little lost when compared with intraoperative angle (130.5-138.0°, 134.0° on average). At 12 months after surgery, the height loss of humeral head was 1.8-4.6 mm (mean, 2.0 mm); the passive anteflexion of the shoulder was 130-160° (mean, 148°); the active anteflexion was 120-145° (mean, 136°); the external rotation was 30-65° (mean, 56°); the internal rotation was 15-25° (mean, 19°). And the DASH score was 2-53 (mean, 12); the SF-36 score was 50-95 (mean, 89). According to Neer score for shoulder function, the results were excellent in 10 cases, good in 4 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 87.5%.
ConclusionLocking-plate with an intramedullary fibular allograft for type C2 proximal humeral fracture fixation has satisfactory clinical results because of stable fixation, high clinical outcome scores, and low internal fixation failure.
Objective To analyze the effectiveness of tuberosity suture combined with autogenous bone grafting in reverse total shoulder arthroplasty for elderly patients with proximal humerus fracture. Methods A clinical data of 28 patients with fresh proximal humerus fractures, who met the selection criteria and admitted between June 2014 and April 2022, was retrospectively analyzed. There were 7 males and 21 females. Age ranged from 65 to 81 years, with an average of 73.8 years. The causes of injury were 21 cases of fall, 6 cases of traffic accident, and 1 case of falling from height. The time from injury to operation ranged from 5 to 20 days with an average of 9.2 days. There were 8 cases of Neer three-part fracture and 20 cases of four-part fracture. The reverse total shoulder arthroplasty was performed, and the greater and lesser tuberosities were sutered and reconstructed with autogenous bone grafting. After operation, the Constant score, American Society for Shoulder Surgery (ASES) score, and visual analogue scale (VAS) score were used to evaluate shoulder function and pain; and the active range of motion of the shoulder joint was recorded, including flexion, external rotation, and internal rotation. X-ray films were taken to observe the position of prosthesis. According to the evaluation criteria proposed by Boileau, the healing of greater tuberosity was evaluated, and the effectiveness was compared between the patients with healed and non-healed (displacement and absorption) greater tuberosity. ResultsAll incisions healed by first intention after operation. All patients were followed up 24-106 months, with an average of 60.9 months. At last follow-up, the VAS score of shoulder joint ranged from 0 to 6 (mean, 1.1). The Constant score ranged from 45 to 100 (mean, 80.1). The ASES score ranged from 57 to 100 (mean, 84.7). The active range of motions of shoulder joint were 60°-160° (mean, 118°) in flexion, 0°-50° (mean, 30°) in external rotation, and corresponding to reaching the S5-T8 vertebral body level in internal rotation. During follow-up, no shoulder joint re-dislocation or severe shoulder instability occurred, and no revision surgery was performed. X-ray film reexamination showed that there was no loosening of the prosthesis. According to the evaluation criteria proposed by Boileau, the greater tuberosity fused in 22 cases (78.6%), displaced in 3 cases (10.7%), and absorbed in 3 cases (10.7%). The shoulder joint function and pain related evaluation indicators in the healed group were significantly better than those in the non-healed group (P<0.05). ConclusionTuberosity suture combined with autogenous bone grafting is a relatively simple procedure that provides a reliable fixation for the anatomic recovery of greater and lesser tuberosities and is beneficial for the recovery of shoulder function in elderly patients with proximal humeral fractures.
ObjectiveTo analyze the outcome and prognostic factors of using locking plate for treating proximal humerus fracture.
MethodsBetween January 2005 and January 2012, 45 aged patients with a displaced 3-part or 4-part fracture of the proximal humerus were treated by locking plate. Range of motion and Constant-Mudey score were observed during the follow-up.
ResultsForty-three patients were followed up from 12 to 48 months with an average of 18 months. The mean final Constant-Mudey score was 72.3±9.5 and 6 of them needed a second surgery. In addition to fracture type, other prognostic factors included redisplacement (4 cases, 9.3%), nonunion (3 cases, 7.0%), crashing (3 cases, 7.0%), necrosis of the humeral head (6 cases, 14.0%) and screw cut-out (5 cases, 11.6%). Among the patients with disrupted medial calcar, 4 needed a second surgery at the final follow-up, 3 had redisplacement, 2 had nonunion, and 2 had screw cut-out.
ConclusionLocked screw-plates provide more secure fixation of fracture in aged patients, but the complication rate remains high. We suggest anatomic reduction, and plate and screws position, length of the screws, the medial cortical contact and stability may be the chief prognostic factors affecting the shoulder function following a proximal humeral fracture.
【摘要】 目的 探討切開復位肱骨近端內固定鎖定系統(proximal humeral internal locking system，PHILOS)治療老年肱骨近端骨折的療效。 方法 2008年5月-2009年5月，對22例60歲以上肱骨近端新鮮移位骨折按Neer分型，二部分2例，三部分16例，四部分4例；采用肩前方入路切開復位PHILOS治療。 結果 22例患者獲12～18個月隨訪，平均14.6個月，采用Constant-Murley評分，優8例，良10例，可3例，差1例，優良率81.4%。 結論 切開復位PHILOS治療老年肱骨近端骨折療效肯定。【Abstract】 Objective To discuss the clinical effect of open reduction and internal fixation with the proximal humeral internal locking system (PHILOS) plate in treating elder patients with proximal humeral fracture. Methods From May 2008 to May 2009, we classified 22 cases of fresh displaced proximal humeral fracture according to the Neer classification. All patients were older than 60 years. There were two cases of two-part fracture, 16 cases of three-part fracture and four cases of four-part fracture. The open reduction and internal fixation with PHILOS plate was performed with the anterior deltopectoral approach. Results The 22 patients were followed up for 12 to 18 months with a mean period of 14.6 months. According to Constant-Murley Shoulder Score measurement, eight cases were graded as excellent, 10 good, three fair, and one poor with a excellent and good rate of 81.4%. Conclusion The open reduction and internal fixation with Philos plate is effective in treating elder patients with proximal humeral fracture.
ObjectiveTo assess the effect of surgical treatment or conservative treatment on the clinical outcomes for displaced 3-part or 4-part proximal humeral fractures in elderly patients.
MethodsWe searched CNKI (between January 1979 and April 2014), Wanfang Data (between January 1982 and April 2014), Medline (between January 1946 and April 2014), PubMed (between January 1966 and April 2014), Embase (between January 1974 and April 2014) and Cochrane Database of Systematic Reviews (between January 2005 and April 2014) for randomized controlled trials comparing surgical treatment and conservative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients. The data were extracted and a Meta-analysis was made using RevMan 5.2.
ResultsFive randomized controlled trials with a total of 226 patients were accepted in this Meta-analysis. The differences of Constant scores[WMD=0.48, 95%CI (-4.39, 5.35), P=0.85], incidences of avascular necrosisr of the humeral head[RR=0.66, 95%CI (0.37, 1.16), P=0.15], incidences of nonunion[RR=0.56, 95%CI (0.20, 1.58), P=0.27], incidences of osteoarthritis[RR=0.35, 95%CI (0.10, 1.22), P=0.10] between the two groups were not statistically different. The difference of incidences of additional surgery after primary treatment was statistically significant[RR=3.52, 95%CI (1.18, 10.45), P=0.02].
ConclusionThe results does not support the surgical treatment to improve the shoulder function when compared with conservative treatment for treating elderly patients with displaced 3-part or 4-part proximal humeral fractures. But surgical treatment increases the incidence of additional surgery after primary treatment. Considering surgery can increase the trauma and economic burden of patients, so the conservative treatment is suggested.
Because of the complexity of proximal humeral fractures, the treatment of proximal humeral fractures has always been a challenge for clinicians. The MultiLoc intramedullary nail is a new type of internal fixation device which has been gradually used in the treatment of proximal humeral fractures in recent years. At present, it is mainly used in the Neer two- and three-part fractures, especially surgical neck fractures. Its flexible design can provide personalized and multi-plane fixation for fracture patients, “screw-in-screw” and medial supporting screw can effectively reduce the axial displacement and varus angle of humeral head, and minimally invasive surgical incision can reduce the injury of rotator cuff. This review focuses on the research status and related evidence of the design, operation, prognosis, and postoperative complications of MultiLoc intramedullary nail, in order to provide a theoretical basis for the application of MultiLoc intramedullary nail in fracture treatment, and enhance clinicians’ understanding of MultiLoc intramedullary nail as a new type of internal fixation device.
