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 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 investigate the short-term effectiveness of transverse antecubital incision in the treatment of failed closed reduction of Gartland type Ⅲ supracondylar humeral fractures (SHFs) in children. Methods Between July 2020 and April 2022, 20 children with Gartland type Ⅲ SHFs who failed in closed reduction were treated with internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision. There were 9 boys and 11 girls with an average age of 3.1 years (range, 1.1-6.0 years). The causes of injuries were fall in 12 cases and fall from height in 8 cases. The time from admission to operation ranged from 7 to 18 hours, with an average of 12.4 hours. The healing of the incision and the occurrence of complications such as nerve injury and cubitus varus were observed after operation; the elbow flexion and extension range of motion after removing the gypsum, after removing the Kirschner wire, and at last follow-up were recorded and compared, as well as the elbow flexion and extension and forearm rotation range of motion at last follow-up between healthy and affected sides; the Baumann angle was measured on the X-ray film, and the fracture healing was observed. At last follow-up, the effectiveness was evaluated according to the Flynn elbow function evaluation criteria. ResultsAll incisions healed by first intention, and there was no skin necrosis, scar contracture, ulnar nerve injury, and cubitus varus. Postoperative pain occurred in the radial-dorsal thumb in 2 cases. The gypsum was removed and elbow flexion and extension exercises were started at 2-4 weeks (mean, 2.7 weeks) after operation, and the Kirschner wire was removed at 4-5 weeks (mean, 4.3 weeks). All the 20 patients were followed up 6-16 months, with an average of 12.4 months. The fracture healing time was 4-5 weeks, with an average of 4.5 weeks, and there was no complication such as delayed healing and myositis ossificans. The flexion and extension range of motion of the elbow joint gradually improved after operation, and there were significant differences between the time after removing the gypsum, after removing the Kirschner wire, and at last follow-up (P<0.017). There was no significant difference in the flexion and extension of the elbow joint and the forearm rotation range of motion between the healthy and affected sides at last follow-up (P>0.05). There was no significant difference in Baumann angle between the time of immediate after operation, after removing the Kirschner wire, and at last follow-up (P>0.05). According to Flynn elbow function evaluation standard, 16 cases were excellent and 4 cases were good, the excellent and good rate was 100%. Conclusion The treatment of Gartland type Ⅲ SHFs in children with failed closed reduction by internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision has the advantages of complete soft tissue hinge behind the fracture for easy reduction and wire fixation, small incision, less complications, fast fracture healing, early functional recovery, reliable reduction and fixation, and can obtain satisfactory results.
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 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 explore the effectiveness of thumb blocking technique through closed reduction of ulnar Kirschner wire threading in the treatment of Gartland type Ⅲ supracondylar humerus fractures in children. MethodsThe clinical data of 58 children with Gartland type Ⅲ supracondylar humerus fractures treated with closed reduction of ulnar Kirschner wire threading by thumb blocking technique between January 2020 and May 2021 were retrospectively analyzed. There were 31 males and 27 females with an average age of 6.4 years ranging from 2 to 14 years. The causes of injury were falling in 47 cases and sports injury in 11 cases. The time from injury to operation ranged from 24.4 to 70.6 hours, with an average of 49.6 hours. The twitch of ring and little fingers was observed during operation, the injury of ulnar nerve was observed after operation, and the healing time of fracture was recorded. At last follow-up, the effectiveness was evaluated by Flynn elbow score, and the complications were observed. Results There was no twitch of the ring and little fingers when the Kirschner wire was inserted on the ulnar side during operation, and the ulnar nerve was not injured. All children were followed up 6-24 months, with an average of 12.9 months. One child had postoperative infection in the operation area, local skin redness and swelling, and purulent secretion exudation at the eye of the Kirschner wire, which was improved after intravenous infusion and regular dressing change in the outpatient department, and the Kirschner wire was removed after the initial healing of the fracture; 2 children had irritation at the end of the Kirchner wire, and recovered after oral antibiotics and dressing change in the outpatient department. There was no serious complication such as nonunion and malunion, and the fracture healing time ranged from 4 to 6 weeks, with an average of 4.2 weeks. At last follow-up, the effectiveness was evaluated by Flynn elbow score, which was excellent in 52 cases, good in 4 cases, and fair in 2 cases, and the excellent and good rate was 96.6%. ConclusionThe treatment of Gartland type Ⅲ supracondylar humerus fractures in children by closed reduction and ulnar Kirschner wire fixation assisted with thumb blocking technique is safe and stable, and will not cause iatrogenic ulnar nerve injury.
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.
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.
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 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.