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ORIGINAL ARTICLE
Year : 2012  |  Volume : 39  |  Issue : 1  |  Page : 12-16

A prospective study to assess the surgical outcome in three- and four-part proximal humerus fracture with PHILOS plate


Department of Orthopedics, J.N.M.C. Belgaum, Karnataka, India

Date of Web Publication21-May-2012

Correspondence Address:
Mahantesh Y Patil
Associate Professor, Department of Orthopedics, J.N.M.C. Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.96462

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  Abstract 

Background: Optimal surgical management of three- and four-part proximal humeral fractures in osteoporotic patients is controversial, with many advocating prosthetic replacement of the humeral head. Proximal humerus interlocking osteosyntheses that maintain angular stability under load have been proposed as an alternative to hemiarthroplasty for the treatment of three- and four-part proximal humeral fractures. Materials and Methods: The records showed 50 patients, with a mean age of 57.5 years. The Neer three-part proximal humeral fractures were 18 in number, and the four-part proximal humeral fractures were 32. All the patients were treated surgically between January 2008 and December 2010. All patients had a radiographic and clinical follow-up performed at one, three, and six months and at one year. The clinical outcomes were measured with the use of the Constant-Murley system. This study was based on level 1 of the evidence. Results: The mean Constant score (and standard deviation) at the time of the final follow-up was better in the locked-plate group. The mean Constant score was 80 (range, 40 - 100). Complications with this fixation included osteonecrosis in one patient, malunion in one patient, Axillary nerve palsy in one patient, and impingement syndrome in one patient. Conclusions: The most important factor for a favorable outcome in three- and four-part fractures in the proximal end humerus gives an accurate anatomical reduction, which is achieved by locking plate osteosynthesis, with multiplanar screws. It is a safe and effective method, with minimal tissue damage, higher primary stability, and load transfer through the implant, which are important to avoid complications. The PHILOS Plate produces promising functional outcomes.

Keywords: PHILOS plate, three- and four-part proximal humeral fractures, angular stable osteosynthesis


How to cite this article:
Patil MY, Patil A B, Balemane S. A prospective study to assess the surgical outcome in three- and four-part proximal humerus fracture with PHILOS plate. J Sci Soc 2012;39:12-6

How to cite this URL:
Patil MY, Patil A B, Balemane S. A prospective study to assess the surgical outcome in three- and four-part proximal humerus fracture with PHILOS plate. J Sci Soc [serial online] 2012 [cited 2017 Apr 28];39:12-6. Available from: http://www.jscisociety.com/text.asp?2012/39/1/12/96462


  Introduction Top


Proximal humerus fractures are one of the most common fractures occurring in the elderly population. These account for approximately 4 - 5% of the fractures. [1] The fractures occur more commonly in elderly patients after the cancellous bone in the humeral neck has been weakened by senility and osteoporosis. [2] Due to the increasing incidence of high velocity trauma this has complicated fracture patterns in the proximal humerus. The management of this has been an enigma, because of the numerous muscle attachments, weak bone, and paucity of space for fixing an implant in the fracture of the proximal humerus.

The three- and four-part fractures represent 13 to 16% of the proximal humerus fractures. These displaced and unstable fractures are difficult to manage and have a high morbid outcome.

The treatment goal is to achieve a painless shoulder, with full function. Various methods have been described including k-wire fixation, rush nailing, intramedullary nailing, plating, and prosthesis replacement.

The suitable treatment for these fractures is still debatable, as most of these fractures are liable to a failure of osteosynthesis, avascular necrosis (AVN) of the humeral head, and also a nonunion / malunion of the fracture, which may all result in a painful shoulder, with poor outcome. Moreover prosthesis replacement of four-part humeral fractures has also yielded unsatisfactory results, with regard to the function. [3],[4]

To overcome the complication associated with this fracture, AO-ASIF has recently developed a new plate (PHILOS), which aims to preserve the biological integrity of the humeral head and secure an anatomical reduction, with multiple screws and angular stability. The PHILOS plate results in enhanced osteosynthesis and stability. This has lower rates of implant failure and subsequent loss of reduction, allowing early mobilization and an improved clinical outcome. [5],[6]

The purpose of this study is to analyze our experience from the use of the PHILOS Plate for treatment of the three- and four-part proximal humerus fracture.


  Materials and Methods Top


Between January 2008 and December 2010, 50 unstable, displaced proximal humerus fractures (24 males, 26 females), in which the type three fractures were 18 and type 4 were 32 [Figure 1] and [Figure 2], were treated. All were treated with open reduction internal fixation, with the PHILOS plate. The mean age of the patients was 57.5 years (40 to 75 years) [Table 1].
Figure 1: Pre-op X-ray

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Figure 2: CT scan with 3D reconstruction

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Table 1: Demographic data

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The inclusion criteria consisted of age > 18 years and a closed three- and four-part displaced, unstable, proximal humeral fracture, that is, an angulation of the articular surface of more than 45° and a displacement between the major fracture fragments of more than1 cm. The patients with a fracture older than the four weeks or a h / o pathological fracture were excluded.

Scheduled follow-up controls were performed at one, three, and six months and one year, including a measure of the active and passive range-of-motion and strength of the involved shoulder. The functional outcome was assessed according to the scoring of the Constant (Constant and Murley 1987) score. The Constant score was graded as poor (0 - 55 points), moderate (56 - 70 points), good (71 - 85 points), or excellent (86 - 100 points) [Table 2].
Table 2: Constant scoring system

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Operative technique

The patients were operated within five days of the injury. All patients received a prophylactic dose of 1.5 g of Cefuroximine intravenously, preoperatively. A deltopectoral approach [Figure 3] was used, with the patient in a beach-chair position. The fragments were indirectly reduced with the help of traction sutures, which were placed in the insertions of rotator cuff tendons, and by extremity rotation. When acceptable reduction was obtained, the PHILOS plate was placed at least 1 cm distal to the upper end of the greater tuberocity and fixed to the humeral shaft. An aiming device was then attached to the upper part of the plate, and the head fragments were secured with Kirschner wires, after image intensifier control. The required lengths of the locking head screws were determined with a direct measuring device, and four to sixlocking screws were then inserted using a specially designed hexagonal screwdriver. The arm was placed in a humeral pouch after wound closure. Passive elevation, pendulum, and rotation exercises were started on the second or third postoperative day. Active range-of-motion exercises with terminal stretching exercises were started at four to six weeks.
Figure 3: Intra operative

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  Results Top


In the setting of a prospective study we operated 50 patients in our hospital. Twenty-six of these patients were females (52%). Twenty-four cases were males (48%). Overall, the mean age was 57.5 years. According to the Neer classification system 18 fractures were type 3, two cases were lost to follow-up (36%), 32 cases were type 4, and four cases were lost follow-up (64%) [Table 3].
Table 3: Results

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Patients were followed up for one, three, and six months and one year [Figure 4] and [Figure 5]. The follow-up rate was 82%. All fractures healed in a satisfactory position. One patient had a malunion with a valgus four-part fracture. The humeral head was in a valgus position, with lesser tuberosity displaced internally and the greater tuberosity displaced superiorly. No wound infections, vascular injuries or loss of fixation were noted. Two patients with axillary nerve palsy recovered spontaneously, within three months. One patient developed avascular necrosis.
Figure 4: Post op X-rays

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Figure 5: Follow up after 6 month

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According to the Constant score, the functional outcomes were excellent in seven (18%) patients, good in 27 (60%), moderate in six (15%), and poor in two (7%). The mean Constant score was 80 (range, 40 - 100).

The shoulder range of movement was excellent in 34 (76%), moderate in eight (20%), and poor in two (4%).

Five patients were seen with impingement symptoms on abduction. There was no significant difference in outcomes between patients with three-part and four-part fractures. Thirty-four (77.2%) patients were able to return to their pre-injury activity level.


  Discussion Top


The three- and four-part fracture represents 13 to 16% of the proximal humerus fracture. These displaced and unstable fractures are difficult to manage and have a high morbidity rate.

The goal of the treatment is to achieve a painless shoulder with good functional outcome. Various methods have been used including k-wire fixation, rush nailing, intramedullary nailing, plating, and prosthesis replacement.

The suitable treatment for these fractures are still debatable, as most of these fractures are liable to a failure of osteosynthesis, AVN of the humeral head or also a nonunion / malunion of the fracture, which may all result in a painful shoulder, with poor outcome. Moreover, prosthetic replacement of humeral head fractures has also yielded unsatisfactory results, with regard to the function.

The other modalities of treatment such as simple T-plate fixation, with two cancellous screws in the humeral head, resulted in a high failure rate in elderly patients with osteoporotic bones. Tension band wiring and non-operative treatment had similar functional outcomes. T-plate fixation also had a high complication rate, including deep infection, impingement needing plate removal, and avascular necrosis. A hemiarthroplasty was recommended in elderly patients with poor bone stock. Although hemiarthroplasty achieved good pain relief; its functional results were unpredictable and its strength poor. Polarus nail fixation yielded good results and it was useful in combined neck and shaft fractures, but the complication rate was high (proximal screw loosening, revision surgery, and lateral metaphyseal comminution, predisposing to implant failure). Revision surgery was required in 17% of the patients due to non-union, avascular necrosis, screw migration, or inadequate position of the implant.

Locking proximal humeral plate fixation achieved acceptable functional results in the elderly and in osteoporotic bones.

In this study, the PHILOS plate fixation provided stable fixation with minimal metallurgy problems, and enabled early range-of-motion, to achieve functionally acceptable results. Nonetheless, the choice of treatment should be based on patient age, functional requirements, bone quality, fracture pattern, and the surgeon's preference. Prospective randomized trials are needed to compare the different methods of fixation.

In this study, the Philos plate fixation was a suitable choice for three- and four-part proximal humeral fractures. Its complication rates were low, probably because these patients were relatively young, and both the bone quality and the surgical technique were good. During dissection and head penetration with the proximal interlocking screws, care had to be taken to avoid damage of the anterior humeral circumflex artery and the axillary nerve. The screw position had to be checked intraoperatively with image intensification.

It is found that in our study 70 to 80% were with good-to-excellent results according to the Constant-Murley scoring system. The shoulder range of movement was excellent in 76%. Around 77% of the patients were able to return to their pre-injury activity level. All fractures healed in a satisfactory position, except in one patient with a valgus four-part fracture, who had avascular necrosis, and another with the malunion. No wound infections, vascular injuries or loss of fixation were noted. Two patients with axillary nerve palsy recovered spontaneously within three months. One patient who ended with the avascular necrosis was operated with hemiarthroplasty.


  Conclusion Top


The most important factor for the favorable outcome in three- and four-part fracture in the humerus is a good anatomical reduction, which is achieved by locking plate osteosynthesis with multiplanar screws and it is a safe and effective method, with minimal tissue damage, higher primary stability, and load transfer through the implant, which are important to avoid complications. The PHILOS Plate produces promising functional outcomes. The suggested surgical approach reduces the risk of soft-tissue damage and provides early functional recovery.

 
  References Top

1.Lind T, Kroser K, Jensen J. The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg 1989;108:285-7.  Back to cited text no. 1
    
2.Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M, Vuori I. Osteoporotic fractures of the proximal humerus in elderly Finnish persons: Sharp increase in 1970-1998 and alarming projections for the new millennium. Acta Orthop Scand 2000;71:465-70.  Back to cited text no. 2
    
3.Paavolainen P, Björkenheim JM, Slätis P, Paukku P. Operative treatment of severe proximal humeral fractures. Acta Orthop Scand 1983;54:374-9.  Back to cited text no. 3
    
4.Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am 2002;84-A:1919-25.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Frigg R. Development of the locking compression plate. Injury 2003;34 Suppl 2:S6-10.  Back to cited text no. 5
    
6.Ring D, Jupiter JB. Internal fixation of the humerus with locking compression plates. Tech Shoulder Elbow Surg 2003;4:169-71.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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