Finite element analysis of PMMA bone cement reinforced screw plate fixation for osteoporotic proximal humeral fracture / 中国骨伤

OBJECTIVE@#With the help of finite element analysis, to explore the effect of proximal humeral bone cement enhanced screw plate fixation on the stability of internal fixation of osteoporotic proximal humeral fracture.@*METHODS@#The digital model of unstable proximal humeral fracture with metaphyseal bone defect was made, and the finite element models of proximal humeral fracture bone cement enhanced screw plate fixation and common screw plate fixation were established respectively. The stress of cancellous bone around the screw, the overall stiffness, the maximum stress of the plate and the maximum stress of the screw were analyzed.@*RESULTS@#The maximum stresses of cancellous bone around 6 screws at the head of proximal humeral with bone cement enhanced screw plate fixation were 1.07 MPa for No.1 nail, 0.43 MPa for No.2 nail, 1.16 MPa for No.3 nail, 0.34 MPa for No.4 nail, 1.99 MPa for No.5 nail and 1.57 MPa for No.6 nail. These with common screw plate fixation were:2.68 MPa for No.1 nail, 0.67 MPa for No.2 nail, 4.37 MPa for No.3 nail, 0.75 MPa for No.4 nail, 3.30 MPa for No.5 nail and 2.47 MPa for No.6 nail. Overall stiffness of the two models is 448 N/mm for bone cement structure and 434 N/mm for common structure. The maximum stress of plate appears in the joint hole:701MPa for bone cement structure and 42 0MPa for common structure. The maximum stress of screws appeared at the tail end of No.4 nail:284 MPa for bone cement structure and 240.8 MPa for common structure.@*CONCLUSION@#Through finite element analysis, it is proved that the proximal humerus bone cement enhanced screw plate fixation of osteoporotic proximal humeral fracture can effectively reduce the stress of cancellous bone around the screw and enhance the initial stability after fracture operation, thus preventing from penetrating out and humeral head collapsing.

Clinical study of double plate system in the treatment of complex proximal humeral fractures in the elderly / 中国骨伤

OBJECTIVE@#To explore the clinical outcomes of anteromedial combined with lateral locking plate for complex proximal humeral fractures in the eldery.@*METHODS@#From June 2018 to October 2020, 30 patients who underwent surgical treatment for Neer grade 3 to 4 proximal humeral fractures, including 8 males and 22 females, aged from 51 to 78 years old with an average of (61.5±7.5) years old. Of them, 15 patients had fractures fixed with anteromedial combined with lateral locking plate(ALLP group), whereas 15 received internal fixation with proximal humerus locking plate only(PHLP group). The clinical data, simple shoulder test (SST), humeral head height loss, varus angle and shoulder range of motion were compared between the two groups.@*RESULTS@#All fractures were healed. The follow-up time ranged from 12 to 24 months, with an average of(14.3±2.9) months. The operation time of ALLP group was longer than that of PHLP group (P<0.05). There was no significant difference in intraoperative blood loss between the two groups (P>0.05). There was no significant difference in SST score between the two groups at 1, 3 and 12 months after operation (P>0.05). In terms of radiographic measurement, there was no significant difference in humeral head height loss and varus angle between the two groups at 1 and 3 months after operation (P>0.05). At 12 months after operation, the height loss and varus angle of humeral head in ALLP group were lower than those in PHLP group (P<0.05). In shoulder range of motion, the range of forward elevation in ALLP group was larger than that in PHLP group 1 year after operation(P<0.05). There was no significant difference in external rotation between the two groups.@*CONCLUSION@#Anteromedial combined with lateral locking plate in the treatment of complex proximal humeral fractures in the elderly can increase the stability of the medial column and obtain a good fracture prognosis. But there are also disadvantages such as longer operation time, so it should be individualized according to the fracture type of the patient.

Tuberosity Healing after Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: Is there Clinical Improvement? / Consolidação dos tubérculos na artroplastia reversa do ombro após fratura proximal do úmero: Existe melhoria nos resultados funcionais?

Abstract Objective To compare the functional results of patients with complex proximal humerus fracture submitted to total shoulder reverse arthroplasty with and without tuberosity healing. The secondary goal was to know the tuberosity healing rate after reverse shoulder arthroplasty with our surgical technique. Methods A retrospective, cohort type study, with a prospective database collection. In total, 28 patients fulfilled the inclusion criteria: age ≥ 65 years, reverse shoulder arthroplasty for complex proximal humerus fracture (type-3 or -4, according to Neer), and a minimum of 24 months of follow-up. At six months of follow-up, all of the patients were evaluated radiographically for tuberosity, and then they were divided into 2 groups: those with healed tuberosities and those with non-healed tuberosities. A clinical evaluation using the Constant score, active range of motion and the Visual Analog Scale (VAS) at the last follow-up was also performed. Results Tuberosity healing occurred in 21 patients (76.3%). There were statistically significant differences in the Constant scoring system (p < 0.001), forward elevation (p = 0.020), internal rotation (p = 0.001) and external rotation (p = 0.003) when comparing the group of healed tuberosities with the group of non-healed tuberosities. No differences were found regarding the VAS score. Conclusion Tuberosity healing results in an improvement of the functional outcomes of patients submitted to reverse shoulder arthroplasty as a treatment for complex proximal humeral fractures in the elderly.

Resumo Objetivo Comparar os resultados funcionais entre pacientes com fratura complexa do úmero proximal submetidos a artroplastia reversa com tubérculos consolidados e tubérculos não consolidados. O objetivo secundário foi determinar a taxa de consolidação dos tubérculos com este tipo de prótese. Métodos Estudo de tipo coorte, retrospectivo, com coleta prospectiva de dados. No total, 28 pacientes cumpriram os critérios de inclusão: idade superior a 65 anos, prótese reversa do ombro por fratura complexa do úmero proximal (3 ou 4 partes, segundo Neer), e tempo de seguimento mínimo de 24 meses. Aos seis meses, todos os pacientes foram avaliados radiograficamente quanto à consolidação dos tubérculos e divididos em dois grupos: grupo com tubérculos consolidados e grupo com tubérculos não consolidados. A avaliação funcional realizou-se segundo o sistema de pontuação de Constant, da amplitude de movimento ativo, e da Escala Visual Analógica (EVA) à data da última consulta. Registaram-se todas as complicações. Resultados A consolidação dos tubérculos ocorreu em 21 pacientes (76,3%). Verificou-se diferenças estatisticamente significativas no sistema de pontuação de Constant (p < 0.001), elevação anterior (p = 0.020), rotação interna (p = 0.001) e externa (p = 0.003), quando se comparou o grupo dos tubérculos consolidados com o grupo dos tubérculos não consolidados. Não houve diferenças significativas na EVA entre os 2 grupos. Conclusão A consolidação dos tubérculos traduz uma melhoria dos resultados funcionais em pacientes submetidos a artroplastia reversa do ombro como tratamento de fraturas complexas do úmero proximal em idosos.

Alteración de mediciones radiográficas en osteosíntesis de húmero proximal con clavo centromedular / Alteration of X-ray measurements in proximal humerus osteosynthesis with intramedullary nail

Resumen: Introducción: La calidad de reducción en las fracturas de húmero proximal es posible valorarla a través de criterios radiográficos (ACD = ángulo cervicodiafisario; OM = offset medial; DTC = distancia tuberosidad-cabeza y ES = espacio subacromial), los cuales predicen la funcionalidad. Sin embargo, estos criterios establecidos para otros implantes no están descritos para el clavo centromedular. Material y métodos: Estudio de cohorte observacional y retrospectivo en pacientes > 18 años con osteosíntesis con clavo centromedular (durante el período de 2014 a 2017), en donde se evaluaron las características demográficas, severidad de lesión (clasificación de Neer) y las mediciones radiográficas progresivas y complicaciones. Resultados: Se analizaron 84 casos, cuya edad en promedio fue de 65 ± 2 años y la media de seguimiento de 13.9 meses. Por clasificación de Neer: 40.4% fueron grado II; 29.7%, grado III y 29.7%, grado IV. La consolidación en varo aumenta 10.7% al final del seguimiento, siendo aquellos pacientes Neer grado III y IV los más frecuentes. La deformidad > 140o predomina para Neer grado II (n = 15/34). En 30.9%, se presenta un cambio de ACD (ΔACD) ≥ 10o. En general, 86.9% tiene cambios de DTC < 5 mm. En los casos Neer grado III/IV, 32% tiene una alteración de ES > 5 mm. La complicación más frecuentemente es la necrosis avascular (NAV) con 44% de los casos. Conclusiones: Las mediciones radiográficas presentan cambios en valoraciones a largo plazo. Las alteraciones en ACD (> 10o) y ES (> 5 mm) se dan en mayor proporción en aquellos pacientes Neer grado III/IV (acorde con la severidad de la fractura), lo que favorece consolidaciones viciosas en varo o valgo y una mayor presencia de NAV.

Abstract: Introduction: The quality of reduction in proximal humerus fractures is valuable with radiographic criteria (Neck-shaft angle [NSA]; medial offset [MO]; distance head tuberosity [DHT] and subacromial space [SS]) that predict functionality. These criteria set for other implants are not described for the intramedullary nail. Material and methods: Observational cohort study, retrospective, with patients > 18 years, with osteosynthesis with intramedullary nail (2014 to 2017), evaluating demographic characteristics, severity of injury (Neer classification), progressive radiographic measurements and complications. Results: 84 cases with an average age of 65 ± 2 years and an average follow-up of 13.9 months were analyzed. By Neer rating 40.4% were grade II, 29.7% grade III and 29.7% grade IV. Consolidation in varus increases to 10.7% at the end of follow-up, with Neer III and IV patients. The >140o deformity is prevalent for Neer II (n = 15/34). 30.9% have a change of neck-shaft angle of ≥ 10o. Overall 86.9% has HTD changes < 5 mm. Cases Neer III/IV 32% has alteration of SS > 5 mm. The most common complication is avascular necrosis (AVN) with 44% of cases. Conclusions: Radiographic measurements have changes in long-term follow-up. Alterations in NSA (> 10o) and SS (> 5 mm) occur in higher proportion of Neer III/IV patients, according to the severity of the fracture, favoring vicious consolidations in varus or valgus and increased presence of AVN.

Inter/intra-observer evaluation between radiographs and tomographies for proximal humerus fracture / Avaliação inter e intra-observador entre radiografias e tomografias para fratura de úmero proximal

ABSTRACT Objective: The use of images in 3D reconstruction is an instrument that facilitates the interpretation of the fracture, observations of deviations, rotations and articular surface. Objective: To evaluate the inter-observer and intra-observer reliability of the Neer x AO proximal humerus fracture classification on radiographs versus computed tomography with three-dimensional reconstruction (3D). Methods: We evaluated the digital radiographs (anteroposterior and profile) and computerized tomography with 3D reconstruction of patients presenting with a proximal humerus fracture, surgically treated at an Orthopedics and Traumatology Service. All radiographs and computed tomography were classified (Neer and AO) by eight (8) orthopedic surgeons, specialists in the upper limb and sent, following the pre-established numeration by the author, in a spreadsheet to the author of the study. Results: The Neer and AO scores were more reproducible when determined by computed tomography with 3D reconstruction, mainly in fractures of greater complexity (Neer 4 parts and AO group C). However, in absolute values, inter and intra-observer reproducibility and concordance still remain low. Conclusion: Computed tomography with 3D reconstruction allows a better analysis of fractures of group C and Neer 4 parts. However, the inter and intra-observer agreement does not increase significantly in comparison to the radiographs. Level of evidence III, Study of non-consecutive patients, without gold standard, applied uniformly.

RESUMO Objetivo: O uso de imagens em reconstrução 3D são um instrumento facilitador na interpretação da fratura, observações dos desvios, rotações e superfície articular. Objetivo: Avaliar a confiabilidade inter-observador e intra-observador da classificação da fratura de úmero proximal, descrita por Neer x AO, em radiografias versus tomografias computadorizadas com reconstrução tridimensional (3D). Métodos: Avaliamos as radiografias digitais (anteroposterior e perfil) e tomografias computadorizadas com reconstrução 3D de pacientes que apresentavam fratura de úmero proximal, tratados cirurgicamente em um Serviço de Ortopedia e Traumatologia. Todas as radiografias e tomografias computadorizadas foram classificadas (Neer e AO) por oito (8) cirurgiões ortopédicos especialistas em membro superior e enviadas, seguindo a numeração pré-estabelecida pelo autor, em uma planilha para o autor do trabalho. Resultados: A classificação de Neer e AO foram mais reprodutíveis quando determinadas pela tomografia computadorizada com reconstrução 3D, principalmente em fraturas de maior complexidade (Neer 4 partes e AO grupo C). Porém, em valores absolutos, a reprodutibilidade e concordância inter e intraobservador ainda permanecem baixas. Conclusão: A tomografia com reconstrução 3D, permite uma melhor análise das fraturas do grupo C e Neer 4 partes. Entretanto, não aumenta significativamente a concordância global inter e intraobservador em comparação as radiografias. Nível de Evidência III, Estudo de pacientes não consecutivos, sem padrão ouro, aplicados uniformemente.

Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture / 中国修复重建外科杂志

Objective: To summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture. Methods: Between June 2014 and January 2018, 17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated. There were 8 males and 9 females, aged from 52 to 78 years (mean, 63.8 years). The infection occurred at 19-66 months after the initial internal fixation (mean, 34.8 months). Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases. The preoperative Constant score, American shoulder and elbow surgeons (ASES) score, and visual analogue scale (VAS) score were 36.41±8.65, 31.06±7.43, and 7.29±0.99, respectively. The preoperative ranges of forward flexion, abduction, external rotation were (45.88±12.46), (42.18±12.31), and (16.76±4.92)°, respectively. The preoperative range of internal rotation was buttock in 9 cases, lumbosacral joint in 3 cases, L 3 in 5 cases. At the first-stage surgery, the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation. After the infections disappeared, the two-stage reverse total shoulder arthroplasty was performed. The mean interval between the two procedures was 4.2 months (range, 3.0-6.5 months). Results: All the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred. All patients were followed up 15-32 months (mean, 22.0 months). At last follow-up, the ranges of forward flexion, abduction, and external rotation were (109.00±23.66), (98.53±16.92), (41.41±6.82)°, respectively; and the range of internal rotation was lumbosacral joint in 5 cases, L 3 in 8 cases, T 12 in 4 cases. The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion ( P<0.05). The Constant score (64.88±8.70), ASES score (65.18±8.10), and VAS score (2.94±1.25) were significantly superior to the preoperative scores ( P<0.05). X-ray films showed that no prosthesis loosening occurred. Conclusion: Two-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture, which has advantages of low risk of infection recurrence, good shoulder function, and satisfactory short-term effectiveness.

Research progress in treatment of proximal humeral fracture with fibular allograft and locking plate / 中国修复重建外科杂志

Objective: To review the research progress in the treatment of proximal humeral fractures with fibular allograft and locking plate. Methods: The literature about the treatment of proximal humeral fractures with fibular allograft and locking plate was reviewed and analyzed from the aspects such as the biomechanics, imaging prognosis, and clinical prognosis. Results: Fibular allograft and locking plate can provide effective medial support for proximal humeral fracture and increase the strength of internal fixation system. Compared with locking plate, fibular allograft combined with locking plate can maintain better humeral neck-shaft angle and the humeral head height after operation in the treatment of proximal humeral fractures, and has better shoulder mobility and shoulder joint function, and does not increase the risk of complications. Conclusion: Fibular allograft combined with locking plate may be a new and effective treatment for proximal humeral fractures. However, the long-term follow-up results are insufficient, the final outcome of fibula is uncertain, and the long-term potential adverse reactions caused by this treatment are still indefinite.

Meta-analysis of intramedullary nail and locking plate in the treatment of proximal humeral fractures / 中国组织工程研究

BACKGROUND: Proximal humeral fractures are one of the most common types of upper limb fractures In adults. With the aging of the population, the Incidence of proximal humeral fractures has been increasing in recent years, and its treatment is still controversial. OBJECTIVE: To compare the clinical efficacy of locking plate and intramedullary nail in the treatment of proximal humeral fractures using meta-analysis. METHODS: We retrieved PubMed, the Cochrane Library, Embase, CNKI, Wanfang, and VIP database to collect studies on intramedullary nail and locking plate in the treatment of proximal humeral fractures. In accordance with the inclusion and exclusion criteria, studies were included. Data were extracted from the included studies. Continuous variables (Constant score, operation time, blood loss) and binary classification variables (total complications, postoperative infection, screw cutout and internal fixation failure, humerus head necrosis, secondary surgery, and acromial impact) were analyzed, and considered as evaluation indexes for the meta-analysis. Statistical software Stata12.0 was used to analyze the data. RESULTS AND CONCLUSION: (1) A total of 8 articles and 891 patients were included, and 9 data were analyzed. (2) The amount of blood loss (SMD=-1.82, 95%C/: -2.77—0.87, P 0.05). (3) These results confirmed that intramedullary nailing is superior to locking plate in operation time and intraoperative blood loss in the treatment of proximal humeral fractures. The results were similar in total complication rate, common complication rate and postoperative recovery of shoulder joint function between the two groups.

Biomechnical stability of proximal humeral fracture fixated by a locking plate plus different fibular allografts / 中华创伤骨科杂志

Objective To investigate the ability of locking plate construct plus fibular autograft that varies in way of augmentation to withstand varus stresses in a model of proximal humeral fracture.Methods Wedge osteotomy was conducted in the humeral surgical necks of 12 shoulders from 6 cadaveric specimens to create models of proximal humeral fracture.There were 3 males and 3 females;their average age at death was 83 years (from 75 to 87 years).The 12 left and right cadaveric humeri were randomly divided into equal groups A and B (n =6) for autogenous iliac bone graft.All the fibular autografts were harvested without distinction from the thinnest and even part of the fibular shaft.A fibular autograft of 8 cm was placed vertically in group A while a fibular autograft of 6 cm was placed slantly in group B.After the fractures were fixated with the proximal humerus internal fixation locking system (PHILOS),varus stress was repeatedly applied to the proximal humerus until the internal fixation failed in the fracture model.The 2 groups were compared in terms of number of compression,number of compression leading to 1 mm deformation,and average shape variable after each press.Results Cut-out of the lateral cortex of the humeral head by the humeral screw and plate loosening to different extents were observed in both groups.The number of compression leading to internal fixation failure was 31,338 ± 5,994 for group A and 30,608 ± 8,015 for group B;the number of compression leading to 1 mm deformation was 2,808 ± 1,501 for group A and 3,153 ±2,024 for group B;the average shape variable after each press was 0.52 ±0.39 μm/time for group A and 0.53 ±0.47 μm/time for group B.All the above comparisons between the 2 groups showed no significant differences (P ＞ 0.05).Conclusion As locking plate construct plus slant fibular autograft augmentation provides no more strength to withstand repetitive varus stresses than locking plate construct plus vertical fibular autograft augmentation,it is not necessary to adopt the former way of augmentation in clinic practice for proximal humeral fracture.

Conservative Treatment of Proximal Humeral Fracture

A proximal humeral fracture is an osteoporotic fracture that often occurs in elderly women. Approximately 80% of all proximal humeral fractures are non-displaced fractures, which can be treated with conservative treatment to achieve stable union. The treatment plan for fractures involving displaced and comminuted fractures is controversial. Malunion, avascular necrosis of the humeral head, and shoulder stiffness due to conservative treatment can occur but the functional deterioration is low and the patient satisfaction is high. The indications for the conservative management of proximal humeral fractures include a non-displaced fracture and a 2-part fracture, low-functional demanded 3-part fracture, and operative-limited 4-part fracture. Recently, the surgical indications have expanded as technological advances in surgical fixation methods and functional needs of elderly patients are increasing. Current treatment policy decisions tend to be determined by the personal preference and expert opinion rather than by evidence-based decision-making.

Clinic study on 47 cases of Neer Ⅱ and Ⅲ proximal humeral fractures treated with proximal humeral internal locking system / 重庆医学

Objective To investigate the clinic efficacy of proximal humeral internal locking system(PHILOS) in the treatment of Neer Ⅱ and Ⅲ proximal humeral fractures.Methods From January 2013 to December 2015,a total of 47 patients with Neer Ⅱ and Ⅲ proximal humeral fractures was treated with PHILOS fixation in our hospital.The operative time,blood loss in operation,hospital stay,complications,Constant scores and radiography films were retrospectively analyzed.Results All 47 patients were followed up for an average of (19.2 ±9.6) month.The average operative time,the level of average intraoperative blood loss,the mean hospitalization time and the complication rate were(95.6 ±43.1) min,(108 ± 41.6) mL,(11.3 ±3.2) d and 14.7 ％ respectively.The Constant score was improved from(21.74 ± 8.24) preoperatively to(82.83 ± 7.21) at the last follow-up,and the difference was statistically significant(t=-36.57,P＜0.01).Conclusion Fixation with PHILOS is a safe and effective treatment for patients with Neer Ⅱ and Ⅲ proximal humeral fractures.

Value of improved photography position for post-operative evaluation of proximal humeral fracture / 医疗卫生装备

Objective To compare the values of two photography positions for the evaluation after locking plate implantation of the proximal humeral fracture patient.Methods Totally 200 proximal humeral frature patients after locking plate implantation had the front and lateral shoulder joint X-ray films with the conventional and improved photography positions analyzed retrospectively.Post-operative evaluation was carried out with double-blind method from the aspects of morphology of humeral head,condition of locking plate and screw,humeral head angle and bone cortex around humerus.Results Improved photography position behaved better than the conventional position in displaying morphology of humeral head,condition of locking plate and screw,humeral head angle and bone cortex around humerus.Conclusion Improved photography position is recommended to photograph the lateral side of the locking plate for post-operative evaluation.

"Time-angle measurement" reduction evaluation technique and clinical evaluation of proximal humerus fracture / 北京大学学报(医学版)

Objective:To evaluate the functional outcome and the complication rate after open reduction and internal fixation of proximal humeral fractures with a "time-angle measurement" reduction evaluation technique,to assess the acceptance of the fracture reduction and to estimate the result of the surgery.Methods:Forty-six patients [mean age:(66.2 ± 14.9) years] with an acute proximal humeral fracture were managed with open reduction and internal fixation with this reduction evaluation technique from January 2012 to December 2013.According to the Neer classification,there were 6 two-part fractures,25 three-part fractures and 15 four-part fractures.The functional outcome was evaluated for each patient using the Constant-Murley score;radiographic evaluation was also conducted and complications were recorded.The postoperative shoulder function recovery and imaging findings were followed up to evaluate the guiding significance of this reduction evaluation technique in the clinical treatment of this kind of fracture.Results:In the study,46 patients had been followed up for 13-36 months,and the average follow-up time was (23.5 ± 7.3) months.All the patients achieved fracture healing 3 months after operation.The average head-shaft angle was (124 ± 3.5) degrees.According to the Constant scoring system,29 patients (63％) had excellent,14 patients (30％) had good,and 3 patients (7％) had poor results.The most common complications were pain (7/65) and restricted movement of the shoulder (5/ 46).There were no cases of screw penetration,necrosis of humeral head,deep tissue infection,nonunion of fracture and axillary nerve injury after operation.Conclusion:For appropriate cases of displaced proxinal humeral fractures,surgical treatment with application of "time-angle measurement" reduction evaluation technique that was introduced in the present study can lead to a good functional outcome,and the technique of reduction assessment should be regarded as a reasonable reference standard in the treatment of displaced proximal humerus fracture.

Influence of Early Bisphosphonate Administration for Fracture Healing in Patients with Osteoporotic Proximal Humerus Fractures

BACKGROUND: Bisphosphonates are generally known to adversely affect fracture healing because they inhibit osteoclastic bone resorption. However, some authors argue that bisphosphonates have no adverse effect on the restoration of the mechanical integrity of long bones after fractures. It is unclear whether bisphosphonates can be initiated safely in patients with acute proximal humerus fractures. The aim of this study was to determine whether the early use of a bisphosphonate affects healing and outcomes of osteoporotic proximal humerus fractures treated with a locking compression plate. METHODS: Between August 2004 and June 2013, a total of 82 osteoporotic patients who underwent locking plate fixation of proximal humerus fractures were enrolled retrospectively. The patients were divided into two groups according to the timing of the commencement of treatment with alendronate after surgery: group A (n = 34, initiation of the bisphosphonate treatment within two weeks after surgery) and group B (n = 48, control group, initiation of the treatment three months after surgery). Patients were assessed for radiographic union at 2, 6, 10, and 16 weeks, 6 months, and 1 year after surgery. Clinical assessments were performed using the Constant score and American Shoulder and Elbow Surgeons (ASES) score at 1 year after surgery. RESULTS: No significant differences were observed between the two groups with respect to radiographic and clinical outcomes after locking plate fixation. All patients obtained fracture union, and the mean time to radiographic union was similar in group A and group B (6.3 and 6.6 weeks, respectively; p = 0.67). CONCLUSIONS: This study shows that the early initiation of bisphosphonate treatment does not affect bone union or clinical outcomes in patients with an osteoporotic proximal humerus fracture treated by locking compression plate fixation.

The Adequacy of Diagnosis and Treatment for Osteoporosis in Patients with Proximal Humeral Fractures

BACKGROUND: The purpose of this study was to evaluate whether physicians' practice was adequate for the diagnosis and treatment of osteoporosis in patients with proximal humeral fracture over the age of 50 years, which is one of major osteoporotic fractures. METHODS: A retrospective nation-wide cohort study was performed using data collected in 2010 by the Korean Health Insurance Review Agency. The incidences of fractures around the hip, spine, and proximal humerus in patients more than 50 years of age, the frequencies of diagnostic bone density scan for osteoporosis, and the prescription for the osteoporosis medication were analyzed and compared. RESULTS: A search of database identified 48,351 hip fractures, 141,208 spine fractures, and 11,609 proximal humeral fractures in patients more than 50 years of age in 2010. Among these patients, 12,097 (25.0%) of hip fractures, 41,962 (29.7%) of spine fractures, and 1,458 (12.6%) of proximal humeral fractures underwent diagnostic bone density scan (p < 0.001); 4,773 (9.9%) of hip fractures, 27,261 (19.3%) of spine fractures, and 639 (5.5%) of proximal humeral fractures were managed with at least one medication approved for the treatment of osteoporosis (p < 0.001). Furthermore, 1,217 (2.5%) of hip fractures, 7,271 (5.2%) of spine fractures, and 188 (1.6%) of proximal humeral fractures received diagnostic bone density scans as well as osteoporosis medications (p < 0.001). Younger patients (50–69 years of age) were less likely to be evaluated and managed for osteoporosis relative to older patients (≥ 70 years of age) (p < 0.001); and men were less likely to be evaluated and managed for osteoporosis relative to women (p < 0.001). CONCLUSIONS: Current physicians' practice pattern may be inadequate for the diagnosis and treatment of osteoporosis in patients of proximal humeral fractures over the age of 50 years. Additional study and educational programs are necessary to improve this care gap, beginning with physicians who are responsible for the fracture treatment and shoulder diseases.

Efficacy of Additive Trans-cuff Augmentation Sutures for Proximal Humeral Fractures Stabilized by Locking Plates in Elderly Patients

BACKGROUND: The purpose of our study was to evaluate the functional and radiologic outcomes of additive augmentation sutures through rotator cuff for proximal humeral fractures stabilized locking plate in elderly patients. METHODS: We enrolled 74 patients over the age of 60 years who received internal fixation using locking plates for proximal humeral fractures. Of these, 50 patients had additive augmentation sutures through rotator cuff. The mean age at the time of surgery was 72.1 years (range, 60-89 years), and the mean follow-up period was 17.5 months (range, 12-62 months). The humeral neck-shaft angle and humeral head height were used as radiological markers to assess the effect of additive augmentation sutures through rotator cuff. We allocated the patients who received additive augmentation sutures into group A and those who did not into group B. RESULTS: At the final follow-up, the mean Korean Showlder Society score and Constant scores were 88.96 +/- 12.1 and 86.6 +/- 11.9, respectively, in group A and 86.21 +/- 11.8 and 85.3 +/- 11.7, respectively, in group B (p=0.368, 0.271). At the final follow-up, the mean loss in humeral neck-shaft angle from the time of immediate postoperative measurement was 1.6degrees in group A and 4.8degrees in group B, whereas the mean loss in humeral head height was 0.82 mm in group A and 0.52 mm in group B (p=0.029, 0.178). CONCLUSIONS: The surgical outcomes of internal fixation using locking plates for proximal humeral fractures were clinically and radiologically good in elderly patients over the age of 60 years without any observable complications. Further, the loss of humeral head shaft angle at the final follow-up from its initial postoperative measurement was significantly smaller in patients who received an additive augmentation suture than in those who did not. Thus, we conclude that augmentation sutures are a beneficial option for elderly patients that clinicians can consider at the time of surgical decision making.

Efficacy of Additive Trans-cuff Augmentation Sutures for Proximal Humeral Fractures Stabilized by Locking Plates in Elderly Patients

BACKGROUND: The purpose of our study was to evaluate the functional and radiologic outcomes of additive augmentation sutures through rotator cuff for proximal humeral fractures stabilized locking plate in elderly patients. METHODS: We enrolled 74 patients over the age of 60 years who received internal fixation using locking plates for proximal humeral fractures. Of these, 50 patients had additive augmentation sutures through rotator cuff. The mean age at the time of surgery was 72.1 years (range, 60-89 years), and the mean follow-up period was 17.5 months (range, 12-62 months). The humeral neck-shaft angle and humeral head height were used as radiological markers to assess the effect of additive augmentation sutures through rotator cuff. We allocated the patients who received additive augmentation sutures into group A and those who did not into group B. RESULTS: At the final follow-up, the mean Korean Showlder Society score and Constant scores were 88.96 +/- 12.1 and 86.6 +/- 11.9, respectively, in group A and 86.21 +/- 11.8 and 85.3 +/- 11.7, respectively, in group B (p=0.368, 0.271). At the final follow-up, the mean loss in humeral neck-shaft angle from the time of immediate postoperative measurement was 1.6degrees in group A and 4.8degrees in group B, whereas the mean loss in humeral head height was 0.82 mm in group A and 0.52 mm in group B (p=0.029, 0.178). CONCLUSIONS: The surgical outcomes of internal fixation using locking plates for proximal humeral fractures were clinically and radiologically good in elderly patients over the age of 60 years without any observable complications. Further, the loss of humeral head shaft angle at the final follow-up from its initial postoperative measurement was significantly smaller in patients who received an additive augmentation suture than in those who did not. Thus, we conclude that augmentation sutures are a beneficial option for elderly patients that clinicians can consider at the time of surgical decision making.

The Result of Conservative Treatment of Proximal Humerus Fracture in Elderly Patients

PURPOSE: With the increase in the old age population, proximal humerus fractures have been increasing recently. However, complications after operative treatment, such as fixation failure, are common because of osteoporosis. We treated proximal humerus fractures in patients with osteoporosis conservatively, and evaluated the radiographic and functional results by analyzing the factors affecting the results. MATERIALS AND METHODS: Nineteen out of 30 cases for whom the clinical follow-up was over 1 year were included in this retrospective study. There were 17 females and 2 males, and the mean age was 73.2 years. The causes were slip from a short height (18 cases) and a minor car accident (1 case). We evaluated the union period, nonunion, malunion and the Constant score and analyzed several factors affecting the functional result, such as age, fracture pattern, and malunion. RESULTS: Seventeen cases (89.5%) obtained union within 12.8 weeks on average. Neck-shaft angle was 125.3degrees on average, with seven cases of malunion. The Constant score was 84.1 on average, and there were excellent scores in 11 cases, good scores in 4 cases, and fair scores in 2 cases. Fracture pattern, neck-shaft angle, or malunion did not affect the functional outcome, and elderly patients showed poorer shoulder function. CONCLUSION: Proximal humeral fractures with osteoporosis may achieve a high rate of bony union when treated with conservative methods. Despite the common occurrence of malunion, a satisfactory functional outcome may be expected.

Locking Plate for Proximal Humeral Fracture in the Elderly Population: Serial Change of Neck Shaft Angle

BACKGROUND: We conducted this radiographic study in the elderly population with proximal humeral fracture aiming to evaluate 1) the serial changes of neck-shaft angle after locking plate fixation and 2) find relationship between change in neck shaft angle and various factors such as age, fracture pattern, severity of osteoporosis, medial support and initial reduction angle. METHODS: Twenty-five patients who underwent surgical treatment for proximal humeral fracture with locking plate between September 2008 and August 2010 are included. True anteroposterior and axillary lateral radiographs were made postoperatively and at each follow-up visit. Measurement of neck shaft angle was done at immediate postoperative, 3 months postoperative and a final follow-up (average, 11 months; range, 8 to 17 months). Severity of osteoporosis was assessed using cortical thickness suggested by Tingart et al. RESULTS: The mean neck shaft angles were 133.6degrees (range, 100degrees to 116degrees) at immediate postoperative, 129.8degrees (range, 99degrees to 150degrees) at 3 months postoperative and 128.4degrees (range, 97degrees to 145degrees) at final follow-up. The mean loss in the neck-shaft angle in the first 3 months was 3.8degrees as compared to 1.3degrees in the period between 3 months and final follow-up. This was statistically significant (p = 0.002), indicating that most of the fall in neck shaft angle occurs in the first three months after surgery. Relationship between neck shaft angle change and age (p = 0.29), fracture pattern (p = 0.41), cortical thickness (p = 0.21), medial support (p = 0.63) and initial reduction accuracy (p = 0.65) are not statistically significant. CONCLUSIONS: The proximal humerus locking plate maintains reliable radiographic results even in the elderly population with proximal humerus fracture.

Comparison of Radiologic and Clinical Results between Locking Compression Plate and Unlocked Plate in Proximal Humerus Fractures

PURPOSE: The purpose of this study is to compare the results of using a locking compression plate and an unlocked plate for treating proximal humeral fractures. MATERIALS AND METHODS: This study was based on 20 patients who underwent plate fixation for proximal humeral fractures out of the 87 patients with proximal humeral fractures and who were admitted from 2003 to 2007 in our hospital. Of the 20 patients, 10 were treated with a locking compression plate and the other 10 were treated with an unlocked plate. Each group was evaluated according to the humeral neck shaft angle, the period until bony union, the complications and the Constant score. The humeral neck shaft angle was based on plain x-rays taken immediately after the operation and at 6 months postoperatively. The Constant score was evaluated on the last visit to our clinic. RESULTS: There was no significant statistical difference between the two groups in terms of the neck shaft angle, the period until bony union and the Constant score. Yet, there were three cases of screw migration in the unlocked plate group. CONCLUSION: There was no significant difference between the two groups in terms of the neck shaft angle, the period until bony union and the Constant score. The locking compression plate is considered to achieve more effective fixation for proximal humerus fractures because there were less complications such as screw migration.