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.
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.
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.
ObjectiveTo review the research progress on intra-articular screw penetration in proximal humeral fracture treated with locking plate. MethodsThe domestic and foreign literature about the proximal humeral fracture treated with locking plate was extensively reviewed. The incidence of screw penetration and risk factors were summarized from both primary and secondary screw penetrations, and the reasons of the intra-articular screw penetration and the technical solutions to avoid the penetration were analyzed. ResultsThe incidence of intra-articular screw penetration is about 11%-30%, which includes primary and secondary screw penetrations. The primary screw penetration is related to improper operation, inaccurate measurement, and “Steinmetz solid” effect, which results in inadequate fluoroscopy and blind zone. The secondary screw penetration is related to the loss of reduction and varus, collapse, and necrosis of the humeral head. The risk factors for intra-articular screw penetration include the bone mass density, the fracture type, the quality of fracture reduction, the applied location, number, and length of the plate and screws, and whether medial column buttress is restored. Improved fracture reduction, understanding the geometric distribution of screws, good intraoperative fluoroscopy, and reconstruction of medial column buttress stability are the key points for success. ConclusionThe risk of the intra-articular screw penetration in the proximal humeral fractures treated with locking plates is still high. Follow-up studies need to further clarify the cause and mechanism of screw penetration, and the risk factors that lead to screw penetration, in order to effectively prevent the occurrence of this complication.
目的:回顧性研究人工肱骨頭置換治療復雜肱骨近端骨折患者的肩關節的情況,以進一步提高療效。方法:對我院2004年至2007年27例肱骨近端骨折患者采用肱骨頭置換術治療,術中修復關節囊和肩袖,術后隨訪5~38月,評價其肩關節功能。結果:采用半關節成形改良評分系統SSMH綜合評分,優:5例,良:17例,可:5例,優良率:815%。肩關節活動:平均前屈上舉:96°,外旋:36°,內旋至L2水平。X片示假體無松動斷裂,位置良好。結論:對于復雜的肱骨近端骨折,人工肱骨頭置換是有效治療手段,能夠最大限度恢復期肩關節活動功能。
Objective To compare the effectiveness and shoulder function of reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF) in the treatment of Neer three/four-part proximal humeral fractures in the elderly. Methods Randomized controlled analysis was conducted on 68 patients over 70 years old with Neer three/four-part proximal humeral fractures treated with RTSA or ORIF between January 2020 and June 2022. The patients were randomly divided into RTSA group (n=32) and ORIF group (n=36). There was no significant difference (P>0.05) in the baseline data such as age, gender, body mass index, injured side, Neer classification, and preoperative Charlson comorbidity index, visual analogue scale (VAS) score, Constant shoulder score, Oxford shoulder score (OSS), and hemoglobin (Hb). The operation time, intraoperative blood loss, reduction of Hb on the 3rd day after operation, hospital stay, total cost of hospitalization, complication incidence, range of motion of shoulder joint at 2 years after operation, VAS score before operation and at 5 days and 1 month after operation, Constant shoulder score and OSS score before operation and at 2 years after operation, and imaging results during follow-up were recorded and compared between the two groups.ResultsCompared with the ORIF group, the RTSA group had longer operation time, less intraoperative blood loss, and higher total cost of hospitalization (P<0.05). There was no significant difference in Hb reduction on the 3rd day after operation between the two groups (P>0.05). The VAS scores significantly improved in both groups at 5 days and 1 month after operation (P<0.05), but there was no significant difference between the two groups (P>0.05). All patients were followed up 26-35 months, with an average of 31.2 months. In the RTSA group, there were 2 cases of poor healing of superficial incision and 1 case of transient nerve injury. There was no complication such as bone resorption around the prosthesis, lucent band, prosthesis loosening, or periprosthetic fracture in all patients. In the ORIF group, there was 1 case of poor healing of superficial incision, 3 cases of nonunion of fracture, 1 case of arthritis secondary to humeral head necrosis, and 1 case of bone absorption of large tuberosity, and no displacement or fracture failure of internal fixation was found in all patients. There was no significant difference in the incidence of complications [9.4% (3/32) vs 16.7% (6/36)] between the two groups [OR (95%CI): 0.828 (0.171, 4.014), P=0.814]. In the RTSA group, 28 cases were graded 0 and 4 cases were graded 1 at 2 years after operation. Constant and OSS scores of RTSA group were significantly better than those of ORIF group (P<0.05). The Constant score was significantly better than ORIF group in activity and strength, range of motion, lifting, abduction, and external rotation (P<0.05), and there was no significant difference in pain, daily function, and internal rotation between the two groups (P>0.05). The RTSA group had a significantly greater range of motion in lifting, abduction, and external rotation than ORIF group (P<0.05), but there was no significant difference in internal rotation between the two groups (P>0.05). ConclusionApplication of RTSA as the initial treatment of Neer three/four-part proximal humeral fractures in the elderly can achieve better rehabilitation of joint activity and lower risk of early reoperation, and improve the quality of life of elderly fracture patients. However, the difficulty of revision and the high cost of treatment require the surgeon to pay full attention and strictly grasp the indications.
ObjectiveTo observe the influence of different humeral neck-shaft angle on the efficacy in the treatment of proximal humeral fractures with locking plate. MethodsA total of 106 patients with proximal humeral fractures were treated by locking plate between March 2009 and March 2013, and the clinical data were retrospectively analyzed. Of 106 cases, 58 were male and 48 were female, aged from 26 to 71 years (mean, 52.3 years). The causes were traffic accident injury in 54 cases, falling injury from height in 23 cases, falling injury in 21 cases, and others in 8 cases. According to the Neer classification, there were 32 cases of two-part fractures, 65 cases of three-part fractures, and 9 cases of four-part fractures. The time from injury to operation was 1-7 days (mean, 2.7 days). According to neck-shaft angle by X-ray measurements at 1-3 days after operation, the patients were divided into 3 groups:valgus group (>145°), normal group (126-145°), and varus group (<126°) to observe the influence of neck-shaft angle on efficacy. ResultsAccording to postoperative humeral neck-shaft angle, there were 10 cases in valgus group, 75 cases in normal group, and 21 cases in varus group. There was no significant difference in general clinical data among 3 groups (P>0.05). The patients were followed up 6-12 months. The X-ray results showed fracture healing, and no significant difference was found in fracture healing time among 3 groups (P>0.05). After 6 months, the varus angle of femoral head and visual analogue scale (VAS) score of normal group were significantly lower than those of valgus group and varus group (P<0.05). The excellent and good rate of Constant-Murley score was 78.67% (59/75) in normal group, and it was significantly higher than that in valgus group (60.00%, 6/10) and varus group (42.86%, 9/21) (P<0.05), but there was no significant difference between valgus group and varus group (P>0.05). The complication rate was 28.57% (6/21) in varus group, was 10.67% (8/75) in normal group, and was 20.00% (2/10) in valgus group, showing no significant difference among 3 groups (χ2=4.31, P=0.12). ConclusionReconstruction of normal neck-shaft angle is the key to good shoulder function and clinical efficacy in the treatment of proximal humeral fracture.
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.
ObjectiveTo explore the biomechanical stability of the medial column reconstructed with the exo-cortical placement of humeral calcar screw by three-dimensional finite element analysis. MethodsA 70-year-old female volunteer was selected for CT scan of the proximal humerus, and a wedge osteotomy was performed 5 mm medially inferior to the humeral head to form a three-dimensional finite element model of a 5 mm defect in the medial cortex. Then, the proximal humeral locking plate (PHILOS) was placed. According to distribution of 2 calcar screws, the study were divided into 3 groups: group A, in which 2 calcar screws were inserted into the lower quadrant of the humeral head in the normal direction for supporting the humeral head; group B, in which 1 calcar screw was inserted outside the cortex below the humeral head, and the other was inserted into the humeral head in the normal direction; group C, in which 2 calcar screws were inserted outside the cortex below the humeral head. The models were loaded with axial, shear, and rotational loadings, and the biomechanical stability of the 3 groups was compared by evaluating the peak von mises stress (PVMS) of the proximal humerus and the internal fixator, proximal humeral displacement, neck-shaft angle changes, and the rotational stability of the proximal humerus. Seven cases of proximal humeral fractures with comminuted medial cortex were retrospectively analyzed between January 2017 and December 2020. Locking proximal humeral plate surgery was performed, and one (5 cases) or two (2 cases) calcar screws were inserted into the inferior cortex of the humeral head during the operation, and the effectiveness was observed. Results Under axial and shear force, the PVMS of the proximal humerus in group B and group C was greater than that in group A, the PVMS of the internal fixator in group B and group C was less than that in group A, while the PVMS of the proximal humerus and internal fixator between group B and group C were similar. The displacement of the proximal humerus and the neck-shaft angle change among the 3 groups were similar under axial and shear force, respectively. Under the rotational torque, compared with group A, the rotation angle of humerus in group B and group C increased slightly, and the rotation stability decreased slightly. All the 7 patients were followed up 6-12 months. All the fractures healed, and the healing time was 8-14 weeks, with an average of 10.9 weeks; the neck-shaft angle changes (the difference between the last follow-up and the immediate postoperative neck-shaft angle) was (1.30±0.42)°, and the Constant score of shoulder joint function was 87.4±4.2; there was no complication such as humeral head varus collapse and screw penetrating the articular surface. ConclusionFor proximal humeral fractures with comminuted medial cortex, exo-cortical placement of 1 or 2 humeral calcar screw of the locking plate outside the inferior cortex of the humeral head can also effectively reconstruct medial column stability, providing an alternative approach for clinical practice.