ObjectiveTo investigate the effectiveness of total elbow arthroplasty (TEA) with preservation of triceps brachii insertion approach.MethodsBetween January 2012 and September 2017, 17 patients with elbow disease were treated with TEA with preservation of triceps brachii insertion approach. There were 3 males and 14 females, with an average age of 65.2 years (range, 48-85 years). The injuries located on left elbow in 5 cases and on right elbow in 12 cases. There were 11 cases of distal humerus fracture (AO type C1 in 2 cases and type C3 in 9 cases); the interval between fracture and operation was 3-10 days (mean, 4.1 days). There were 3 cases of osteoarthritis and 3 cases of rheumatoid arthritis, with the disease duration of 2-26 years (mean, 8.7 years). The postoperative elbow function and pain was assessed by Mayo elbow performance score (MEPS) and visual analogue scale (VAS) score, respectively. The prosthesis position, heterotopic ossification, and periprosthetic fracture were observed by X-ray films.ResultsAll incisions healed by first intention. Sixteen patients were followed up 18-69 months (mean, 40.6 months). Intraoperative ulnar nerve injury occurred in 2 cases, and healed after symptomatic treatment. At last follow-up, the MEPS score was 55-100 (mean, 90.3). The results were excellent in 11 cases, good in 2 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 81.3%. The VAS score was 0-2 (mean, 0.4). X-ray reexamination showed that no polyethylene wear, prosthesis loosening and fracture, abnormal prosthesis position, periprosthetic fracture occurred during the follow-up period, and the prosthesis survival rate was 100%. Heterotopic ossification occurred in 2 and 3 months after operation in 2 cases, respectively.ConclusionThe triceps on approach for TEA are satisfactory for distal humerus fracture, osteoarthritis, and rheumatoid arthritis.
ObjectiveTo compare the effectiveness between paratricipital approach and chevron olecranon V osteotomy approach for the treatment of type C3 (AO/OTA) distal humeral fractures and investigate the details of operation.MethodsBetween April 2010 and September 2016, 36 type C3 (AO/OTA) distal humeral fractures were treated with open reduction and bicolumnar orthogonal locking plating fixation by paratricipital approach and chevron olecranon V osteotomy approach respectively. The patients were divided into 2 groups by approach, there were 17 cases in paratricipital group (group A) and the bicolumns and distal humeral joint surface were exposed by traction of triceps and olecranon, and the distal humeral joint surface of the 19 cases in chevron olecranon V osteotomy group (group B) were exposed by osteotomy of the olecranon and reversing of triceps. There was no significant difference in gender, age, dominant side, interval between injury and surgery, causes of injury between 2 groups (P>0.05). Patients were followed up, the postoperative range of motion of elbow joint, strength, pain, and stability in 2 groups were documented and compared; the elbow joint function was evaluated according to Mayo elbow performance score (MEPS).ResultsThe operation time of group A [(115.0±10.4) minutes] was less than that of group B [(121.0±12.3) minutes], but there was no significant difference (t=–1.580, P=0.123). All patients in 2 groups got over 1 year follow-up and there was no significant difference of the follow-up time between 2 groups (t=–0.843, P=0.405). There was 1 case of heterotopic ossification in each group; 1 case of incision infection in group A and 1 case of incision superficial infection in group B, and were cured after 2 weeks of intravenous antibiotics administration. There was no other operative complications in the 2 groups. At 3 months after operation, all the distal humerus healed. At last follow-up, the elbow flexion extension range of groups A and B were (102.0±12.6)° and (99.5±10.1)° respectively, showing no significant difference (t=–0.681, P=0.501). The MEPS scores of groups A and B were 82.9±7.3 and 81.3±7.2 respectively, showing no significant difference (t=0.670, P=0.507); and the evaluation grade also showed no significant difference between 2 groups (Z=–0.442, P=0.659).ConclusionBy paratricipital approach and proper traction of the olecranon, the distal humeral articular surface can be exposed in the operation of type C3 distal humeral fractures, followed with same stable fixation after reduction, the effectiveness is equal to by chevron olecranon V osteotomy approach.
Objective To evaluate the effectiveness of percutanous fixation with helical bridge combined fixation system (BCFS) for treatment of long split fractures involving the middle and upper humerus. Methods Between February 2018 and February 2020, 15 patients of long split fractures involving the middle and upper humerus were treated. There were 6 males and 9 females, with an average age of 62 years (range, 37-82 years). The fractures were caused by slipping in 7 cases, falling from height in 3 cases, and traffic accident in 5 cases. According to AO classification, the shaft fractures were rated as type A in 4 cases, type B in 9 cases, and type C in 2 cases. And all fractures extended to proximal humerus; and the proximal fractures were rated as one-part fracture in 11 cases and two-part fracture in 4 cases according to Neer classification. The interval between injury and operation was 1-7 days (mean, 3.2 days). Nine patients underwent closed reduction and 6 patients underwent open reduction after lengthening the incisions. All fractures were percutaneously internal fixated with helical BCFS after reduction. The operation time, intraoperative blood loss, incision healing, and fracture healing were recorded. Constant-Murley score was used to evaluate shoulder joint function, and Mayo score was used to evaluate elbow joint function. ResultsThe operation time ranged from 55 to 175 minutes, with an average of 76.5 minutes; the intraoperative blood loss ranged from 80 to 300 mL, with an average of 185.5 mL. All incisions healed by first intention, without infection or radial nerve injury. All patients were followed up 12-23 months, with an average of 16 months. The fractures all reached clinical healing, and the healing time was 12-20 weeks, with an average of 14.5 weeks. At 1 year after operation, the Constant-Murley score of the affected side was 88.7±7.6, and there was no significant difference when compared with that of the healthy side (90.8±8.3) (t=1.421, P=0.052). According to the elbow Mayo score, the score of the affected side was 97.6±6.5, and there was no significant difference when compared with the healthy side (97.7±7.3) (t=0.433, P=0.913). ConclusionThe helical BCFS can avoid the dissection of deltoid insertion and prevent the iatrogenic radial nerve injury. With satisfied effectiveness, it is suggested for minimally invasive surgical treatment of long split fractures involving the middle and upper humerus.
Objective To compare the biomechanical properties of personalized Y-shaped plates with horizontal plates, vertical plates, and traditional Y-shaped plates in the treatment of distal humeral intra-articular fractures through finite element analysis, and to evaluate their potential for clinical application. Methods The study selected a 38-year-old male volunteer and obtained a three-dimensional model of the humerus by scanning his upper limbs using a 64-slice spiral CT. Four types of fracture-internal fixation models were constructed using Mimics 19.0, Geomagic Wrap 2017, Creo 6.0, and other software: horizontal plates, vertical plates, traditional Y-shaped plate, and personalized Y-shaped plate. The models were then meshed using Hypermesh 14.0 software, and material properties and boundary conditions were defined in Abaqus 6.14 software. AnyBody 7.3 software was used to simulate elbow flexion and extension movements, calculate muscle strength, joint forces, and load torques, and compare the peak stress and maximum displacement of the four fixation methods at different motion angles (10°, 30°, 50°, 70°, 90°, 110°, 130°, 150°) during elbow flexion and extension. Results Under dynamic loading during elbow flexion and extension, the personalized Y-shaped plate exhibits significant biomechanical advantages. During elbow flexion, the peak internal fixation stress of the personalized Y-shaped plate was (28.8±0.9) MPa, which was significantly lower than that of the horizontal plates, vertical plates, and traditional Y-shaped plate (P<0.05). During elbow extension, the peak internal fixation stress of the personalized Y-shaped plate was (18.1±1.6) MPa, which was lower than those of the other three models, with significant differences when compared with horizontal plates and vertical plates (P<0.05). Regarding the peak humeral stress, the personalized Y-shaped plate model showed mean values of (10.9±0.8) and (13.1±1.4) MPa during elbow flexion and extension, respectively, which were significantly lower than those of the other three models (P<0.05). Displacement analysis showed that the maximum displacement of the humerus with the personalized Y-shaped plate during elbow flexion was (2.03±0.08) mm, slightly higher than that of the horizontal plates, but significantly lower than that of the vertical plates, showing significant differences (P<0.05). During elbow extension, the maximum displacement of the humerus with the personalized Y-shaped plate was (1.93±0.13) mm, which was lower than that of the other three models, with significant differences when compared with vertical plates and traditional Y-shaped plates (P<0.05). Stress contour analysis showed that the stress of the personalized Y-shaped plate was primarily concentrated at the bifurcation of the Y-shaped structure. Displacement contour analysis showed that the personalized Y-shaped plate effectively controlled the displacement of the distal humerus during both flexion and extension, demonstrating excellent stability. ConclusionThe personalized Y-shaped plate demonstrates excellent biomechanical performance in the treatment of distal humeral intra-articular fractures, with lower stress and displacement, providing more stable fixation effects.
Objective To evaluate the result of treating nonunion of lower segment of humerus with combination of rib flaps of cross chest and double plates. Methods From Feburary 2000 to May 2006, 21 cases of nounion of lower segment of humerus were treated. There were 13 males and 8 females with an average age of 36.5 years (range, 17-56 years). Accordingto AO classification, there were 5 cases of type A1.3, 7 cases of type B1.3, 6 cases of type B2.3, 2 cases of type B3.3, and 1 case of type C1.3. All nonunion occurred after internal fixation, which was caused by bone resorption at fracture end in 12 cases, by plates breakage in 3 cases, and by internal fixation loosening in 6 cases; including 8 cases of hypertrophic nonunion and 13 cases of atrophy nonunion without pseudoarthrosis. An average time of nonunion was 1.5 years (from 8 months to 3 years). All cases were treated with combination of rib flaps of cross chest (length, 3.0-3.5 cm) and double plates. The pedicle was divided 8 to 10 weeks after operation and all cases carried out functional exercise. Results The patients were followed up for an average time of 18.2 months (range, 1-3 years). All nounion of lower segment of humerus were healed and no radial nerve injury occurred. Primary heal ing of wound was achieved at both donor and recipient sites. Bony union was achieved in all cases after an average time of 3.5 months (range, 3-5 months) after operation. According to the the Hospital for Special Surgery (HSS) functional elbow index, the average score was 89.3 (range, 81.7-92.5) and the outcome was excellent in 14 cases, good in 4 cases, and poor in 3 cases, the excellent and good rate was 85.7%. Conclusion Combination of rib flaps of cross chest and double plates is an effective method of treating nonunion of lower segment of humerus.
Objective To compare the effectiveness of ultrasound- and arthrography-assisted Kirschner wire fixation in the treatment of Jakob type Ⅱ lateral condylar humerus fracture (LCHF) in children. Methods A clinical data of 101 children with Jakob type Ⅱ LCHF, who met the selection criteria and were admitted between April 2021 and April 2022, was retrospectively analyzed. Of them, 47 cases were treated with ultrasound-assisted Kirschner wire fixation (group A), and 54 cases with arthrography-assisted surgery (group B). There was no significant difference in gender, age, cause of injury, fracture side, and disease duration between groups (P>0.05). Intraoperative fluoroscopy times, operation time, and hospital stay, Flynn elbow joint function score, and postoperative complications were recorded and compared between groups. X-ray examination was performed to observe the healing of fracture, and measure the carrying angle and the shaft-condylar angle (SCA). ResultsThe success rate of closed reduction was significantly higher in group A than in group B (P<0.05), and the intraoperative fluoroscopy times was significantly less in group A than in group B (P<0.05). There was no significant difference in operation time and hospital stay between groups (P>0.05). All children in both groups were followed up 12-18 months, with an average of 13.6 months. X-ray reexamination showed that the fractures of both groups healed, and the difference in healing time was not significant (P>0.05). At last follow-up, there was no significant difference in carrying angle and SCA between unaffected side and affected side in both groups and between groups A and B in affected side (P>0.05). There was no significant difference in Flynn elbow joint function score between groups (P>0.05). There were 18 cases of lateral spurs formation in group A, 1 case of pinning infection and 26 cases of lateral spurs formation in group B, and there was no significant difference in the incidence of the above complications (P>0.05). ConclusionCompared with the arthrography, the ultrasound-assisted Kirschner wire fixation in the treatment of Jakob type Ⅱ LCHF in children can avoid the open reduction and decrease the number of intraoperative fluoroscopy, and obtain the good effectiveness.
Objective To compare the effectiveness of early versus delayed closed reduction and percutaneous Kirschner wire fixation in the treatment of pediatric supracondylar humerus fractures. Methods A retrospective analysis was conducted on 468 children with supracondylar humerus fractures, who were admitted between January 2020 and December 2023 and met the inclusion criteria. Among them, 187 children were treated during 12 hours after injury (early operation group) and 281 were treated after 12 hours (delayed operation group). There was no significant difference between the two groups (P>0.05) in the gender, age, injury mechanism, fracture side and type, while there was significant difference in interval from injury to operation (P<0.05). The operative outcomes, including the operation time, intraoperative blood loss, the length of hospital stay, fracture healing time, elbow function assessed by Flynn criteria at 3 months after operation, and complications, were compared. Results Compared to the delayed operation group, the early operation group demonstrated significantly shorter operation time and less intraoperative blood loss (P<0.05). There was no significant difference in the length of hospital stay between the two groups (P>0.05). All children were followed up 3-12 months. The follow-up time was (6.7±2.9) months in the early operation group and (6.9±2.8) months in the delayed operation group, showing no significant difference between the two groups (P>0.05). There was no significant difference in the fracture healing time between the two groups (P>0.05). At 3 months after operation, the early operation group exhibited superior Flynn elbow functional outcomes to the delayed operation group (P<0.05). In the early operation group, there was 1 case of fracture non-union and 3 cases of cubital varus deformity after operation. In the delayed operation group, there was 1 case of nerve injury, 7 cases of fracture non-union, and 12 cases of cubital varus deformity after operation. There was significant difference in the incidence of complications between the two groups (P<0.05). One case of the early operation group and 10 cases of the delayed operation group underwent secondary operation, showing no significant difference in the incidence of secondary operation between the two groups (P>0.05). ConclusionFor pediatric supracondylar humerus fractures, early closed reduction and percutaneous Kirschner wire fixation can reduce operation time, minimize intraoperative blood loss and postoperative complications, and improve the functional recovery compared to delayed operation.
Objective To compare the effectiveness of simultaneous and delayed repair of combined full-thickness rotator cuff rupture in proximal humerus fracture. Methods Between January 2015 and January 2017, 44 patients with proximal humerus fractures complicated with full-thickness rotator cuff injuries were included. Twenty-four patients underwent open reduction and internal fixation (ORIF) and rotator cuff repair simultaneously (simultaneous operation group), and 20 patients underwent delayed arthroscopic rotator cuff repair more than 90 days after ORIF (delayed operation group). There was no significant difference in gender, age, cause of injury, and side of injury between the two groups (P>0.05). The fracture healing was observed by X-ray films. The shoulder function was assessed at 3, 6, and 12 months after operation by using the University of California at Los Angeles (UCLA) score. Results All incisions healed by first intention. All patients were followed up 12-24 months (mean, 17 months). Fractures all healed at 3 months after operation in simultaneous operation group. According to UCLA score, the patients had achieved significantly better outcomes in function, active forward flexion, strength of forward flexion, and subjective satisfaction in simultaneous operation group than in delayed operation group at 3, 6, and 12 months after operation (P<0.05). However, there was no significant difference in pain between the two groups (P>0.05). Conclusion For patients with proximal humerus fracture complicated with full-thickness rotator cuff rupture, performing ORIF and simultaneous repair of rotator cuff can improve shoulder function and achieve better effectiveness when compared with delayed repair of rotator cuff.
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.
ObjectiveTo review the advancement made in the understanding of valgus impacted proximal humeral fracture (PHF). MethodsThe domestic and foreign literature about the valgus impacted PHF was extensively reviewed and the definition, classification, pathological features, and treatment of valgus impacted PHFs were summarized. Results PHF with a neck shaft angle ≥160° is recognized as a valgus impacted PHF characterized by the preservation of the medial epiphyseal region of the humeral head, which contributes to maintenance of the medial periosteum’s integrity after fracture and reduces the occurrence of avascular necrosis. Therefore, the valgus impacted PHF has a better prognosis when compared to other complex PHFs. The Neer classification designates it as a three- or four-part fracture, while the AO/Association for the Study of Internal Fixation (AO/ASIF) categorizes it as type C (C1.1). In the management of the valgus impacted PHF, the selection between conservative and surgical approaches is contingent upon the patient’s age and the extent of fracture displacement. While conservative treatment offers the advantage of being non-invasive, it is accompanied by limitations such as the inability to achieve anatomical reduction and the potential for multiple complications. Surgical treatment includes open reduction combined with steel wire or locking plate and/or non-absorbable suture, transosseous suture technology, and shoulder replacement. Surgeons must adopt personalized treatment strategies for each patient with a valgus impacted PHF. Minimally invasive surgery helps to preserve blood supply to the humeral head, mitigate the likelihood of avascular necrosis, and reduce postoperative complications of bone and soft tissue. For elderly patients with severe comminuted and displaced fractures, osteoporosis, and unsuitable internal fixation, shoulder joint replacement is the best treatment option. ConclusionCurrently, there has been some advancement in the classification, vascular supply, and management of valgus impacted PHF. Nevertheless, further research is imperative to assess the clinical safety, biomechanical stability, and indication of minimally invasive technology.
