Dataset Information

Application of Intramedullary Calcar Support Plate and Lateral Locking Plate in Elderly Patients with Neer 3 and 4-Part Fractures of Proximal Humerus Through a Deltoid Splitting Approach.

ABSTRACT:

Background

The reduction and fixation of Medial humeral calcar is difficult in the treatment of elderly proximal humerus Neer 3 and 4-part fractures with a single lateral locking plate. Our study investigated the efficacy of an intramedullary calcar supporting plate combined with a lateral locking plate for the treatment of 3- and 4-part fractures of the proximal humerus in the elderly through a deltoid splitting approach.

Methods

From June 2022 to December 2022, we treated six elderly patients with Neer 3 and 4-part fractures using proximal humeral intramedullary calcar support plate in combination with lateral locking plate through a deltoid splitting approach. Follow-up time was 6-12 months. Assessment indicators included fracture union, quality of reduction, and complication rate. The Constant-Murley score was used to record shoulder function at 6 months postoperatively.

Results

All 6 patients showed fracture union and anatomic reduction. Constant-Murley score was 79.5 (70-90) at 6 months postoperatively. There was no incision non-healing, internal fixation failure, bone non-union or surgical site infection, secondary surgery, or death. Shoulder impingement occurred in 1 case.

Conclusion

Proximal humeral intramedullary calcar support plate combined with lateral locking plate fixation through a deltoid splitting approach can effectively maintain fracture reduction, prevent inversion collapse of humeral head and internal fixation failure, and provide satisfactory clinical results at an early stage.

Supplementary information

The online version contains supplementary material available at 10.1007/s43465-024-01098-3.

SUBMITTER: Wang Y

PROVIDER: S-EPMC10963710 | biostudies-literature | 2024 Apr

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Application of Intramedullary Calcar Support Plate and Lateral Locking Plate in Elderly Patients with Neer 3 and 4-Part Fractures of Proximal Humerus Through a Deltoid Splitting Approach.

Wang Yijun Y Zhao Liang L Liu Can C Qin Kang K

Indian journal of orthopaedics 20240301 4

<h4>Background</h4>The reduction and fixation of Medial humeral calcar is difficult in the treatment of elderly proximal humerus Neer 3 and 4-part fractures with a single lateral locking plate. Our study investigated the efficacy of an intramedullary calcar supporting plate combined with a lateral locking plate for the treatment of 3- and 4-part fractures of the proximal humerus in the elderly through a deltoid splitting approach.<h4>Methods</h4>From June 2022 to December 2022, we treated six el ...[more]

PMID: 38544541

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Project description:ObjectiveIn complicated Neer three- and four-part proximal humerus fracture (PHF), greater tuberosity (GT) fragments are often comminuted, and the currently widely used locking plate may not fix GT fragments effectively. A further understanding of morphological characteristics of the GT fragments may help explore new fixation devices. This study aimed to determine the fracture line morphology of the GT fragment of Neer three- or four-part PHF and analyze the location relationship between the locking plate and the GT fragment.MethodsSeventy-one three-dimensional computed tomography scans of Neer three- and four-part PHF were retrospectively reviewed between January 2014 and June 2019. Fracture fragments were reconstructed and virtually reduced in the Mimics software, and fracture lines of GT fragments were depicted on a humerus template in the 3-matic software and then were superimposed altogether. The common sites of the GT fracture were identified, and the location relationship between the locking plate and GT fragments was analyzed in a computer-simulated scenario.ResultsThe fracture line morphology of GT fragments was similar between Neer three- and four-part PHF. The overall morphology of GT fragments was in a fan shape, which could be summarized as anterior, superior, posterior, and middle lines. Of these, we identified 51 split and 29 avulsion type GT fragments based on the Mutch classification, and they could occur simultaneously in a PHF. The overall morphology of split type fragments was in a fan shape, and avulsion type fragments showed a quite distinguishable distribution pattern. A GT fragment could be classified as anterior-split, posterior-split, complete-split, anterior -avulsion, and posterior-avulsion type based on its morphology and location. The median percentage of fragment area covered by the plate was 32.3% in all of the fragments, and it was 69.4%, 23.0%, 37.2%, 21.8%, 0.0% in anterior-split, posterior-split, complete-split, anterior-avulsion, and posterior-avulsion type GT fragments. We defined the posterior-split, anterior-avulsion, and posterior-avulsion type GT fragments as the risky GT fragments, and they occurred in 43 (60.6%) Neer three- and four-part PHFs.ConclusionThe fracture line morphology of GT fragments of Neer three- and four-part PHF was in a fan shape. GT fragments could be classified based on their location and morphology. The extent of GT fragment coverage provided by the locking plate differed in various fragment types, and we identified the anterior-avulsion, posterior-avulsion, and posterior-split type fragments as the risky GT fragments with a high incidence rate in Neer three- and four-part PHFs.

Project description:BackgroundProximal humeral fractures are with an incidence of 4-5 % the third most common fractures in the elderly. In 20 % of humeral fractures there is an indication for surgical treatment according to the modified Neer-Criteria. A secondary varus dislocation of the head fragment and cutting-out are the most common complications of angle stable locking plates in AO11-A3 fractures of the elderly. One possibility to increase the stability of the screw-bone-interface is the cement augmentation of the screw tips. A second is the use of a multiplanar angle stablentramedullary nail that might provide better biomechanical properties after fixation of 2-part-fractures. A comparison of these two treatment options augmented locking plate versus multiplanar angle stable locking nail in 2-part surgical neck fractures of the proximal humerus has not been carried out up to now.Methods/designForty patients (female/male, ≥60 years or female postmenopausal) with a 2-part-fracture of the proximal humerus (AO type 11-A3) will be randomized to either to augmented plate fixation group (PhilosAugment) or to multiplanar intramedullary nail group (MultiLoc). Outcome parameters are Disabilities of the Shoulder, Arm and Hand-Score (DASH) Constant Score (CS), American Shoulder and Elbow Score (ASES), Oxford Shoulder Score (OSS), Range of motion (ROM) and Short Form 36 (SF-36) after 3 weeks, 6 weeks, 3 months, 6 months, 12 and 24 months.DiscussionBecause of the lack of clinical studies that compare cement augmented locking plates with multiplanar humeral nail systems after 2-part surgical neck fractures of the proximal humerus, the decision of surgical method currently depends only on surgeons preference. Because only a randomized clinical trial (RCT) can sufficiently answer the question if one treatment option provides advantages compared to the other method we are planning to perform a RCT.Trial registrationClinical Trial ( NCT02609906 ), November 18, 2015, registered retrospectively.

Project description:BackgroundProximal humerus fractures are the third most common in the human body but their management remains controversial. Open reduction and internal fixation with plates is one of the leading modes of operative treatment for these fractures. The development of technologies and techniques for these plates, during the recent decades, promise a bright future for their clinical use. A comprehensive review of in vitro biomechanical studies is needed for the comparison of plates' mechanical performance and the testing methodologies. This will not only guide clinicians with plate selection but also with the design of future in vitro biomechanical studies. This review was aimed to systematically categorise and review the in vitro biomechanical studies of these plates based on their protocols and discuss their results. The technologies and techniques investigated in these studies were categorised and compared to reach a census where possible.Methods and resultsWeb of Science and Scopus database search yielded 62 studies. Out of these, 51 performed axial loading, torsion, bending and/or combined bending and axial loading while 11 simulated complex glenohumeral movements by using tendons. Loading conditions and set-up, failure criteria and performance parameters, as well as results for each study, were reviewed. Only two studies tested four-part fracture model while the rest investigated two- and three-part fractures. In ten studies, synthetic humeri were tested instead of cadaveric ones. In addition to load-displacement data, three-dimensional motion analysis systems, digital image correlation and acoustic emission testing have been used for measurement.ConclusionsOverall, PHILOS was the most tested plate and locking plates demonstrated better mechanical performance than non-locking ones. Conflicting results have been published for their comparison with non-locking blade plates and polyaxial locking screws. Augmentation with cement [calcium phosphate or poly(methyl methacrylate)] or allografts (fibular and femoral head) was found to improve bone-plate constructs' mechanical performance. Controversy still lies over the use of rigid and semi-rigid implants and the insertion of inferomedial screws for calcar region support. This review will guide the design of in vitro and in silico biomechanical tests and also supplement the study of clinical literature.

Project description:IntroductionIn locked plate fixation of proximal humerus fractures, the calcar is an important anchor point for screws providing much-needed medial column support. Most locking plate implants utilize a fixed-trajectory locking screw to achieve this goal. Consequently, adjustments of plate location to account for patient-specific anatomy may result in a screw position outside of the calcar. To date, little is known about the consequences of "missing" the calcar during plate positioning. This study sought to characterize the biomechanics associated with proximal and distal placement of locking plates in a two-part fracture model.Materials and methodsThis experiment was performed twice, first with elderly cadaveric specimens and again with osteoporotic sawbones. Two-part fractures were simulated and specimens were divided to represent proximal, neutral, and distal plate placements. Non-destructive torsional and axial compression tests were performed prior to an axial fatigue test and a ramp to failure. Torsional stiffness, axial stiffness, humeral head displacement and stiffness during fatigue testing, and ultimate load were compared between groups.ResultsCadavers: Proximal implant placement led to trends of decreased mechanical properties, but there were no significant differences found between groups. Sawbones: Distal placement increased torsional stiffness in both directions (p = 0.003, p = 0.034) and axial stiffness (p = 0.018) when compared to proximal placement. Distal placement also increased torsional stiffness in external rotation (p = 0.020), increased axial stiffness (p = 0.024), decreased humeral head displacement during fatigue testing, and increased stiffness during fatigue testing when compared to neutral placement.DiscussionThe distal and neutral groups had similar mechanical properties in many cadaveric comparisons while the proximal group trended towards decreased construct stiffness.Resultsfrom the Sawbones model were more definitive and provided further evidence that proximal calcar screw placements are undesirable and distal implant placement may provide improved construct stability.ConclusionSuccessful proximal humerus fracture reconstruction is inherent upon anatomic fracture reduction coupled with medial column support. Results from this experiment suggest that missing the calcar proximally is deleterious to fixation strength, while it is safe, and perhaps even desirable, to aim slightly distal to the intended target.

Project description:The present review and meta-analysis aimed to summarize the currently available data and to compare the important clinical and functional outcomes in patients with proximal humerus fractures who were treated using deltoid split (DS) or deltopectoral (DP) surgical approaches. The PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases were systematically searched for randomized controlled trials or observational studies that reported functional outcome data of patients with fracture of proximal humerus who were surgically treated using DS and DP approaches. A total of 14 studies were included in the present meta-analysis. The duration of surgery [min; weighted mean difference (WMD), -16.44; 95% CI, -(25.25-7.63)], amount of blood loss [ml; WMD, -57.99; 95% CI, -(102.74-13.23)] and time to bone union [weeks WMD, -1.66; 95% CI, -(2.30-1.02)] was comparatively lower in patients that underwent DS. There were no statistically significant differences in the pain and quality of life scores, range of movement and risk of complications between the DS and the DP groups. Patients in the DS group had improved shoulder function and constant shoulder score (CSS) at 3 months post-surgery (WMD, 6.36; 95% CI, 1.06-11.65). No differences were observed between the two groups in terms of CSS and disabilities of the arm, shoulder and hand scores at 12 and 24 months post-operatively. The activity of daily living (ADL) score was significantly improved in the DS group at 3 (WMD, 1.23; 95% CI, 0.40-2.06), 6 (WMD, 0.99; 95% CI, 0.72-1.25) and 12 months (WMD, 0.83; 95% CI, 0.18-1.47) after the surgery. The present results suggested that DS and DP surgical approaches were associated with similar clinical outcomes. The DS approach was associated with certain perioperative benefits, as well as reduced time to bone union, improved shoulder function in the early postoperative period and improved ADL scores. These benefits may be considered while choosing between these two surgical approaches.

Project description:BackgroundProximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking.Methods and findingsThe primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely.ConclusionsIn this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments.Trial registrationClinicalTrials.gov NCT01246167.

Project description:Joint-preserving surgical treatment of complex unstable proximal humerus fractures remains challenging, with high failure rates even following state-of-the-art locked plating. Enhancement of implants could help improve outcomes. By overcoming limitations of conventional biomechanical testing, finite element (FE) analysis enables design optimization but requires stringent validation. This study aimed to computationally enhance the design of an existing locking plate to provide superior fixation stability and evaluate the benefit experimentally in a matched-pair fashion. Further aims were the evaluation of instrumentation accuracy and its potential influence on the specimen-specific predictive ability of FE. Screw trajectories of an existing commercial plate were adjusted to reduce the predicted cyclic cut-out failure risk and define the enhanced (EH) implant design based on results of a previous parametric FE study using 19 left proximal humerus models (Set A). Superiority of EH versus the original (OG) design was tested using nine pairs of human proximal humeri (N = 18, Set B). Specimen-specific CT-based virtual preoperative planning defined osteotomies replicating a complex 3-part fracture and fixation with a locking plate using six screws. Bone specimens were prepared, osteotomized and instrumented according to the preoperative plan via a standardized procedure utilizing 3D-printed guides. Cut-out failure of OG and EH implant designs was compared in paired groups with both FE analysis and cyclic biomechanical testing. The computationally enhanced implant configuration achieved significantly more cycles to cut-out failure compared to the standard OG design (p < 0.01), confirming the significantly lower peri-implant bone strain predicted by FE for the EH versus OG groups (p < 0.001). The magnitude of instrumentation inaccuracies was small but had a significant effect on the predicted failure risk (p < 0.01). The sample-specific FE predictions strongly correlated with the experimental results (R2 = 0.70) when incorporating instrumentation inaccuracies. These findings demonstrate the power and validity of FE simulations in improving implant designs towards superior fixation stability of proximal humerus fractures. Computational optimization could be performed involving further implant features and help decrease failure rates. The results underline the importance of accurate surgical execution of implant fixations and the need for high consistency in validation studies.

Dataset Information

Application of Intramedullary Calcar Support Plate and Lateral Locking Plate in Elderly Patients with Neer 3 and 4-Part Fractures of Proximal Humerus Through a Deltoid Splitting Approach.

Background

Methods

Results

Conclusion

Supplementary information

Publications

Application of Intramedullary Calcar Support Plate and Lateral Locking Plate in Elderly Patients with Neer 3 and 4-Part Fractures of Proximal Humerus Through a Deltoid Splitting Approach.

Similar Datasets

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