Elsevier

Injury

Volume 47, Issue 2, February 2016, Pages 350-355
Injury

Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures

https://doi.org/10.1016/j.injury.2015.10.001Get rights and content

Abstract

Aim

The aim of this study was to evaluate risk factors for the development of humeral head necrosis and non-union after proximal humeral fractures—in particular, general risk factors that exist independent of fracture type.

Materials and methods

This study included patients (n = 154) treated for proximal humeral fracture by means of open reduction and internal fixation (ORIF) using the Philos® plate at a single level I trauma centre between January 2005 and December 2013. Follow-up monitoring included radiographic examination before hospital discharge, and again at 6 weeks, 12 weeks, and 6 months after surgery. At a minimum follow-up time of 6 months, radiographs taken in the anteroposterior and axial projection were evaluated in regard to the development of humeral head necrosis, non-union, and secondary screw cut out.

Results

A total of 154 patients (61 males, 93 females) were available for radiological checkup. Mean age was 55.8 years (range: 19–91 years). There were statistically significant correlations between the development of avascular necrosis (AVN) and fracture type, non-union and smoking, and screw cut out – as well as overall complication rate – and age. The time to surgery did not influence the risk for AVN or non-union, independent of fracture type. In this study population, the risk of developing non-union after ORIF was 3.9-fold higher in heavy smokers (i.e., >20 cigarettes per day). The risk for screw cut out was 4.1-fold higher in patients over 60 years of age, and the overall risk for complications was 3.3-fold higher.

Conclusion

The older the patient, the more carefully one must consider the decision between conservative and operative treatments. If surgical treatment is performed, screw length should be selected depending on the patient's age. Heavy smokers must be informed preoperatively of the increased risk for bony non-union after ORIF.

Introduction

The incidence of proximal humeral fractures has increased considerably during recent decades [1]. After distal forearm and hip fractures, proximal humeral fractures represent the third most common fracture type [2], [3]—of which 10–20% involve open reduction and internal fixation (ORIF) [2]. Modern orthopedic implants such as locking plates have contributed to the trend towards surgical treatment of these fractures. Internal fixation, offering excellent biomechanical stability even in osteoporotic bone, restores the anatomy of the proximal humerus. Nevertheless, complication rates in proximal humeral fractures after open reduction and plating remain high [4], [5], [6], [7]. The use of locking plates is associated with a high rate of screw cut out—up to 57% depending upon patient's age (and thus representing the most frequent complication) [4], [5], [6], [8], [9], [10]. Avascular humeral head necrosis is seen in 3–35% of patients [9], [11], [12], [13], [14], [15], [16], leading to a time-delayed increase in pain and decrease in range of motion—often requiring subsequent revision surgery. The rate of humeral head non-union after plating has been described in the literature to be as high as 13% [4], [10], [11], [17], [18], [19]. However, outside of a handful of publications [10], [18], [20], [21], [22], [23], [24], [25], [26], there is little information about what influence additional risk factors (e.g., patients’ comorbidities, medications, and smoking habits) may have on the results after open reduction and plating of proximal humeral fractures. Furthermore, little is known about the influence of time to surgery on complications such as humeral head necrosis and non-union.

First, the aim of this study was to evaluate the incidence of humeral head necrosis and non-union after open reduction and plating in proximal humeral fractures. Second, we wanted to evaluate risk factors promoting humeral head necrosis, non-union, and other possible complications after open reduction and plating in proximal humeral fractures.

Section snippets

Patients

Initially, this study included all patients (n = 286) treated at a single level I trauma centre for a proximal humeral fracture with open reduction and internal fixation (ORIF) using the Philos® plate (Synthes, Oberdorf, Switzerland) between January 2005 and December 2013.

Inclusion criteria were as follows: (a) presence of proximal humeral fracture, (b) known time of trauma, (c) surgical treatment with ORIF and Philos® plate (Synthes, Oberdorf, Switzerland), (d) availability of at least 6 months

Results

A total of 286 patients presenting with proximal humeral fracture were treated with ORIF using the Philos® plate (Synthes, Oberdorf, Switzerland) at our level I trauma centre from January 2005 to December 2013. At a minimum follow-up time of 6 months (mean: 479 days), 154 patients were available for radiological checkup. Eventually, 61 males (39.6%) and 93 females (60.4%) were included for the final study analysis. Mean age was 55.8 years (range: 19–91 years). Mean time to surgery was 5.28 days

Discussion

The aim of this study was, first, to evaluate the incidence of humeral head necrosis and non-union after open reduction and plating in proximal humeral fractures. Second, we wanted to evaluate risk factors promoting humeral head necrosis, non-union, and other possible complications after open reduction and plating in proximal humeral fractures. To the best of our knowledge, this is the first study investigating the influence of several risk factors (including time to surgery) on the development

Conclusions

In this study population, we found statistically significant correlations between AVN and fracture type, non-union and smoking, and screw cut out – as well as overall complication rate – and age. Time to surgery did not influence the risk for AVN or non-union, independent of fracture type. The risk for development of non-union after ORIF was 3.9-fold higher in heavy smokers (>20 cigarettes per day). In patients over 60 years of age, the risk for screw cut out was 4.1-fold higher, and the

Conflict of interest

The authors declare not to have any conflict of interest.

References (34)

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