Proximal Humeral Symposium
Pitfalls and complications with locking plate for proximal humerus fracture

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Purpose

The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures.

Patients and Methods

Seventy-threee adult patients with a displaced 3- (24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months.

Results

Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score (P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score (P = .029). Quality of the reduction of the greater tuberosity influenced final results (P = .037). Screw cutout rate was 13.7%, with an influence to the constant score (P = .001). A too high plate positioning influenced the constant score (P = .002).

Conclusion

Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.

Section snippets

Patients and methods

Between 2004 and 2005, 73 acute 3- and 4-part displaced proximal humeral fractures underwent operative treatment with the same fixed angle locking-proximal-humerus-plate (LPHP – SYNTHES, Oberdorf, Switzerland) by different senior surgeons or under the direct supervision of a senior surgeon. During this period of time, no patient with unstable 3- or 4-part fractures has been treated with another technique (hemiarthroplasty, nails or pinning). Patients' charts were reviewed to collect data

Surgical technique

All surgeries were performed within the first week of the injury. An extended deltopectoral approach without detachment of the anterior deltoid was used in 14 cases (19.2%) and an anterosuperior approach through a deltoid-splitting in 59 cases (80.8 %). The periosteal attachment of the tuberosities and the diaphysis was preserved, and the medial hinge as well. The humeral head displacement was reduced to allow reduction of the tuberosities. Their osteosynthesis was performed with the use of

Postoperative follow-up

Patients were clinically and radiographically evaluated postoperatively at 6 weeks, 3, 6, 12 months. Postoperative evaluation for this study was conducted at a minimum of 18 months. Fourty-four patients agreed to come back for clinical and radiographic investigations. Eighteen patients were lost for follow-up: 5 died, 5 moved to another department, and 8 were too old to come back. Eleven patients need a second and a third surgery (4 secondary displacement, 2 screws cut out, 2 pseuarthrosis, 1

Results

Average follow-up was 20.7 months for the 44 patients called back for radiographic and clinical examination (range, 18-40 months). Three patients (4.1%) developed an adhesive capsulitis that needed an arthroscopic release after 2 years of evolution. Those patients had an anatomic reconstruction, without evidence of osteonecrosis or hardware malpositioning. There was 1 deep infection that needed 2 secondary surgeries and, finally, a resection arthoplasty. One patient with a healed fracture

Discussion

Locked fixed-angle screw implants with angular stability have been developed to improve the pullout strength of the screws inserted in a convergent or a divergent manner.8, 13, 14, 19, 25 Theoretically, these plates provide more secure fixation of proximal humeral fractures, especially in weak or oteoporotic bones.28 Nevertheless, the complication rate associated with remains high (over 10%1) and the mode of failure is different than conventional plates. Two types of complications need to be

Conclusion

We would like to emphasis the cutout and complication rate of this osteosynthesis material. We recommend careful consideration of the decision-making between ORIF and fracture-dedicated arthroplasties for 4-part fractures of the proximal humerus in patients with osteopenia, particularly when the bone-stock and the humeral head are thin. There is no real consensus regarding the optimal treatment for such fractures.31 Nevertheless, it has been shown that in a selected cohort of patients,

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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