The Hertel classification can't predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach

ABSTRACT Background: Proximal humeral fractures can progress to osteonecrosis of the humeral head. Hertel developed a binary classification system (12 subtypes) and demonstrated that some patterns have more risk to develop osteonecrosis. Hertel described the prevalence and the risk factors for Humeral head osteonecrosis after osteosynthesis using a Deltopectoral approach. Few studies have evaluated the prevalence and the capacity of Hertel's classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach. The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk of developing osteonecrosis and its prevalence after osteosynthesis using the anterolateral approach. Methods: This was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach. Patients were divided into two groups: high risk for necrosis (group 1) and low risk for necrosis (group 2) according to Hertel's criteria. The overall prevalence of osteonecrosis and the prevalence in each group were calculated. A radiological examination was performed in the true anteroposterior (Grashey), scapular, and axillary views, before and after the operation (minimum 1 year after surgery). A KaplanMeier curve was used to assess the pattern of the temporal evolution of osteonecrosis. The groups were compared using the Chi-square test or Fisher's exact test. The unpaired t-test (parametric variables - age) and the MannWhitney test (non-parametric time between trauma and surgery) were used. Results: In total, 39 patients were evaluated. The postoperative follow-up time was 14.5 ± 3.3 months. The time to onset of necrosis was 14.1 ± 3.9 months. Sex, age, and time between trauma and surgery did not influence the risk of necrosis. Type 2, 9, 10, 11, and 12, or fractures with posteromedial head extension less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, as well as grouping did not influence the risk for osteonecrosis. Conclusions: Hertel's criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach. The total prevalence of osteonecrosis was 17.9% with a tendency toward an increased incidence after 1 year of surgical treatment.

Proximal humeral internal locking system combined with fibular strut allograft for treatment of Neer 3-and 4-part factures of proximal humerus in the elderly / 中华创伤骨科杂志

Objective To compare proximal humeral internal locking system (PHILOS) combined with fibular strut allograft versus simple PHILOS for the treatment of Neer 3-and 4-part factures of proximal humerus in the elderly.Methods A retrospective study was conducted of 157 elderly patients with Neer 3-or 4-part facture of proximal humerus who had been treated at Department of Orthopaedics,Ningbo No.6 Hospital from May 2013 to October 2016.They were 76 males and 81 females,aged from 60 to 88 years (average,76.1 years).According to the Neer classification,100 cases were 3-part fractures and 57 4-part fractures.Of them,35 were treated by PHILOS combined with fibular strut allograft (group A) and 122 by PHILOS alone (group B).At the last follow-up,the 2 groups were compared in terms of shoulder joint activity (anteflexion,abduction,internal rotation and external rotation),visual analogue scale (VAS),American Shoulder and Elbow Surgeons (ASES) score,Constant-Murley score,postoperative height loss of the humeral head,humeral head varus angle,complication rate and secondary surgery rate.Results The 157 patients were followed up for 12 to 22 months (mean,16.8 months).The fracture healing time was 13.0 ± 3.8 weeks in group A and 15.6 ± 4.2 weeks in group B,showing a statistically significant difference (P ＜ 0.05).At the last follow-up,for groups A and B respectively,anteflexion was 135.6° ± 17.7° versus 125.4° ± 23.6°,abduction 132.5°±22.7° versus 117.5°±32.7°,external rotation 30.2°± 18.7° versus 21.6°± 17.2°,internal rotation T9 versus T11,VAS score 0.6 ±0.9 points versus 0.9 ± 1.2 points,ASES score 90.2 ±6.8 points versus 82.2 ± 12.3 points,Constant-Murley score 88.5 ±3.6 points versus 72 ±4.9 points,postoperative height loss of the humeral head 0.9 ± 0.1 mm versus 4.2 ± 0.4 mm,and humeral head varus angle 1.2° ± 0.2° versus 4.5° ± 1.9°.The differences between the 2 groups were all statistically significant (P ＜ 0.05).There were no significant differences between the 2 groups in complication rate [14.28％ (5/35) versus 22.13％ (27/122)] or in secondary operation rate[2.85％ (1/35) versus 8.19％ (27/122)] (P ＞ 0.05).Conclusions In the treatment of Neer 3-and 4-part factures of proximal humerus in the elderly,PHILOS combined with fibular strut allograft can improve therapeutic efficacy,because it can provide good support for the medial column of the proximal humerus and the humeral head and thus facilitate the intraoperative reduction of the fracture.

Treatment for complex scapular fracture with minimally invasive modified Judet approach and annularity internal fixation / 复旦学报（医学版）

Objective To investigate clinical effect of surgical treatment of complex scapular fracture with improved minimally invasive Judet approach and annularity internal fixation.Methods In this retrospective study,17 patients with complex scapular fracture accepted open reduction and internal fixation with improved minimally invasive Judet approach complying with the three points-two lines annularity internal fixation principle.After postoperative rehabilitation training,the curative effect was evaluated by the neer shoulder joint function score evaluation.Results All the 17 patients were followed up for 14 months on average (12-25 months).According to neer score evaluation,the percent of patients with excellent and good results was 88.2％ (excellent:12 cases;good:3 cases;middle:2cases;unsatisfactory:no case).Conclusions Improved minimally invasive Judet approach hase simple operation,adequate exposure and less injury.Annularity internal fixation complying with the three points-two lines principle is a safe and effective method for the treatment of complex scapular fracture.

Displaced Scapula Fracture (Ideberg Type IIb) Combined with a Large Rotator Cuff Tear in Anterior Shoulder Dislocation: A Case Report

Traumatic anterior shoulder dislocation combined with scapular fracture in elderly patients is relatively rare. In this case, a patient visited Emergency Room of Dong-A University Hospital for shoulder pain after falling off a ladder. Radiographs demonstrated anterior shoulder dislocation with displaced Ideberg type IIb scapula (glenoid fossa) fracture combined with a large rotator cuff tear on magnetic resonance imaging. We performed arthroscopic rotator cuff repair, but a large fragment in the inferior glenoid was left untreated. At the 1 year follow-up visit, the pain visual analogue scale of the patient was 2, the American Shoulder and Elbow Society score was 88 and the patient had gained nearly full range of motion without any apprehension.

Displaced Scapula Fracture (Ideberg Type IIb) Combined with a Large Rotator Cuff Tear in Anterior Shoulder Dislocation: A Case Report

Traumatic anterior shoulder dislocation combined with scapular fracture in elderly patients is relatively rare. In this case, a patient visited Emergency Room of Dong-A University Hospital for shoulder pain after falling off a ladder. Radiographs demonstrated anterior shoulder dislocation with displaced Ideberg type IIb scapula (glenoid fossa) fracture combined with a large rotator cuff tear on magnetic resonance imaging. We performed arthroscopic rotator cuff repair, but a large fragment in the inferior glenoid was left untreated. At the 1 year follow-up visit, the pain visual analogue scale of the patient was 2, the American Shoulder and Elbow Society score was 88 and the patient had gained nearly full range of motion without any apprehension.

Operative treatment of the unstable scapular neck fracture / 中华创伤骨科杂志

Objective To explore factors influencing the restdts of operative treatment of unstable scapular neck fractures. Methods We reviewed 15 patients who had been diagnosed as the unstable scapular neck fracture and received operation from June 2001 to November 2007 in our department. Of them, 13 had full follow-up data, with a mean follow-up time of 45.1 (10 to 90) months. There were 8 cases of anatomic scapular neck fracture and 5 cases of surgical scapular neck fracture combined with injury to the superior shoulder suspensory complex. The shoulder posterior approach was adopted, exposing the fracture site between the in-fraspinatus and teres minors interval, to fix the scapular neck fracture along the scapular lateral border and si-multaneously fix the combined clavicle fracture, dislocation of the acromioclavicular joint and acromial process fracture. The results were evaluated by the absolute value of Constant-Murley rating system. Results The average absolute Constant-Murley score was 81.2 (40-98) points. Nine cases were evaluated as excellent and good, 2 cases as fair, and 2 cases as poor. The average forward elevation was 147.7°. Conclusions The degree of displacement is the main factor affecting the prognosis of the scapular neck fracture. Reduction and fixation of the displaced scapular neck fracture is the key to achieving good results.

The value of different imaging methods on classification in displaced proximal humeral fractures / 中华放射学杂志

Objective To investigate the influence of common X-ray, two-dimensional computed tomography (2D-CT), spiral computed tomography (SCT), and three-dimensional (3-D) reconstruction on the classification in displaced proximal humeral fractures. Methods Three groups were divided on the basis of various imaging methods, including group A (common X-ray), group B (common X-ray and 2D-CT), and group C (3-D reconstruction of SCT and 2D-SCT). 46 cases of displaced proximal humeral fractures were classified with Neer system. The true rate of fracture classification by use of three methods was compared with each other, and clinical significance of SCT and 3-D reconstruction was evaluated.Results Based on operation, 46 cases of displaced proximal humeral fractures in group A included 26 cases of Neer two-part fractures, 13 cases of three-part fractures, and 7 cases of four-part fractures. The true cases of common X-ray were 22 in Neer two-part fractures and 8 in three and four-part fractures, there was significant difference between Neer two-part fractures and Neer three and four-part fractures (P

The classification and operative treatment of scapular fractures / 中华骨科杂志

Objective To explore the early diagnosis and surgical treatment of scapular fractures. Methods Sixteen cases with scapular fractures received operation that had been admitted to our hospital from January 1996 to January 2001 were retrospectively analyzed. AP views of X-ray, two-dimensional CT scannings and three-dimensional CT reconstructions were used to confirm the injuries. According to Hardegger's classification for scapular fractures, There were 9 fractures of the scapular body, 7 fractures of the scapular neck, 2 fractures of the glenoid rim, 1 fracture of the glenoid fossa, 5 fractures of the scapular spine, 3 fractures of the acromion and 2 fractures of the coracoid process. Of the 16 patients, 11(68.8%) cases had complex fractures of the scapula, and 14 cases (87.5%) had associated injuries. On the basis of the fracture patterns, anterior, posterior, posterosuperior approach,and anterior combined posterior approach were performed with plates or(and) lag screws for surgical reconstruction. Results All patients were followed up with an average of 18.6 months. According to Rowes evaluation, 11 cases showed excellent results, 2 good, 1 fair, and 2 poor. The glenohumeral posttraumatic arthritis of the series was found in 2 cases, heterotopic ossification in 1 case, and shoulder joint instability in 1 case. Conclusion 1) Scapular fractures are caused by high-energy violence with a high incidence of serious associated injury. Computerized tomography scanning with three-dimensional imaging is helpful to determine the fracture pattern and degree of displacement; 2) Intra-articular fracture of the glenoid fossa with more than 3 to 5 mm of step-off displacement, the glenoid rim fracture combined with humeral head subluxation, grossly displaced fracture of the scapular neck, some bursting fractures of the body, and floating shoulder injuries should be operated; 3) Open reduction and internal fixation is an useful and safe technique for the treatment of specific displaced fractures of the scapula. It needs at least 12 months to determine the final functional result.