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European Journal of Orthopaedic Surgery & Traumatology

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01-05-2021 | Original Article

Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands

Authors: Arie Greenberg, Philip J. Rosinsky, Nir Gafni, Yona Kosashvili, Alexander Kaban

Published in: European Journal of Orthopaedic Surgery & Traumatology | Issue 4/2021

Abstract

Background

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries.

Methods

Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65–85). All completed a minimum 1-year follow-up (range 12.5–82 months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed.

Results

Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates.

Conclusion

Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

Court-Brown CM, Duckworth AD, Clement ND, McQueen MM (2018) Fractures in older adults. a view of the future? Injury 49:2161–2166. https://doi.org/10.1016/j.injury.2018.11.009CrossRefPubMed

Park C, Jang S, Lee A et al (2015) Incidence and mortality after proximal humerus fractures over 50 years of age in South Korea: national claim data from 2008 to 2012. J Bone Metab 22:17–21. https://doi.org/10.11005/jbm.2015.22.1.17CrossRefPubMedPubMedCentral

Maravic M, Briot K, Roux C, des Médecins Rhumatologues CF (2014) Burden of proximal humerus fractures in the French National Hospital Database. Orthop Traumatol Surg Res 100:931–934. https://doi.org/10.1016/j.otsr.2014.09.017CrossRefPubMed

Carbone S, Mezzoprete R, Papalia M et al (2018) Radiographic patterns of osteoporotic proximal humerus fractures. Eur J Radiol 100:43–48. https://doi.org/10.1016/j.ejrad.2017.12.025CrossRefPubMed

Clinton J, Franta A, Polissar NL et al (2009) Proximal humeral fracture as a risk factor for subsequent hip fractures. J Bone Joint Surg Am 91:503–511. https://doi.org/10.2106/JBJS.G.01529CrossRefPubMedPubMedCentral

Calvo E, Morcillo D, Foruria AM et al (2011) Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception. J Shoulder Elb Surg 20:795–801. https://doi.org/10.1016/j.jse.2010.09.008CrossRef

Neer CS (1970) Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 52:1077–1089CrossRef

Marsh JL, Slongo TF, Agel J et al (2007) Fracture and dislocation classification compendium-2007: orthopaedic trauma association classification, database and outcomes committee. J Orthop Trauma 21:S1-133. https://doi.org/10.1097/00005131-200711101-00001CrossRefPubMed

Handoll HHG, Brorson S (2015) Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD000434.pub4CrossRefPubMed

10.

Rangan A, Handoll H, Brealey S et al (2015) Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 313:1037–1047. https://doi.org/10.1001/jama.2015.1629CrossRefPubMed

11.

Nowak LL, Vicente MR, McKee MD et al (2017) Orthopaedic surgeons’ opinions surrounding the management of proximal humerus fractures: an international survey. Int Orthop 41:1749–1755. https://doi.org/10.1007/s00264-017-3569-0CrossRefPubMed

12.

Euler SA, Petri M, Venderley MB et al (2017) Biomechanical evaluation of straight antegrade nailing in proximal humeral fractures: the rationale of the “proximal anchoring point.” Int Orthop 41:1715–1721. https://doi.org/10.1007/s00264-017-3498-yCrossRefPubMed

13.

Michener LA, McClure PW, Sennett BJ (2002) American shoulder and elbow surgeons standardized shoulder assessment form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg 11:587–594. https://doi.org/10.1067/mse.2002.127096CrossRefPubMed

14.

Schmidt S, Ferrer M, González M et al (2014) Evaluation of shoulder-specific patient-reported outcome measures: a systematic and standardized comparison of available evidence. J Shoulder Elbow Surg 23:434–444. https://doi.org/10.1016/j.jse.2013.09.029CrossRefPubMed

15.

LaMartina J, Christmas KN, Simon P et al (2018) Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes. J Shoulder Elbow Surg 27:470–477. https://doi.org/10.1016/j.jse.2017.09.033CrossRefPubMed

16.

Bhat SB, Secrist ES, Austin LS et al (2016) Displaced proximal humerus fractures in older patients: shoulder surgeons versus traumatologists. Orthopedics 39:e509-513. https://doi.org/10.3928/01477447-20160427-08CrossRefPubMed

17.

Kloub M, Holub K, Polakova S (2014) Nailing of three- and four-part fractures of the humeral head–long-term results. Injury 45(1):S29-37. https://doi.org/10.1016/j.injury.2013.10.038CrossRefPubMed

18.

Kloub M, Holub K, Urban J et al (2019) Intramedullary nailing of displaced four-part fractures of the proximal humerus. Injury. https://doi.org/10.1016/j.injury.2019.06.029CrossRefPubMed

19.

Wong J, Newman JM, Gruson KI (2016) Outcomes of intramedullary nailing for acute proximal humerus fractures: a systematic review. J Orthop Traumatol 17:113–122. https://doi.org/10.1007/s10195-015-0384-5CrossRefPubMed

20.

Mehta S, Chin M, Sanville J et al (2018) Calcar screw position in proximal humerus fracture fixation: don’t miss high! Injury 49:624–629. https://doi.org/10.1016/j.injury.2018.02.007CrossRefPubMedPubMedCentral

21.

Xu J, Zhang C, Wang T (2014) Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis. J Orthop Surg Res 9:31. https://doi.org/10.1186/1749-799X-9-31CrossRefPubMedPubMedCentral

22.

Tepass A, Rolauffs B, Weise K et al (2013) Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970–2009. Patient Saf Surg 7:34. https://doi.org/10.1186/1754-9493-7-34CrossRefPubMedPubMedCentral

23.

Capriccioso CE, Zuckerman JD, Egol KA (2016) Initial varus displacement of proximal humerus fractures results in similar function but higher complication rates. Injury 47:909–913. https://doi.org/10.1016/j.injury.2016.01.021CrossRefPubMed

24.

Gadea F, Favard L, Boileau P et al (2016) Fixation of 4-part fractures of the proximal humerus: can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases. Orthop Traumatol Surg Res 102:963–970. https://doi.org/10.1016/j.otsr.2016.09.015CrossRefPubMed

25.

Shi X, Liu H, Xing R et al (2019) Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. J Orthop Surg Res 14:285. https://doi.org/10.1186/s13018-019-1345-0CrossRefPubMedPubMedCentral

26.

Lange M, Brandt D, Mittlmeier T, Gradl G (2016) Proximal humeral fractures: non-operative treatment versus intramedullary nailing in 2-, 3- and 4-part fractures. Injury 47(7):S14–S19. https://doi.org/10.1016/S0020-1383(16)30848-8CrossRefPubMed

27.

Nwachukwu BU, Schairer WW, McCormick F et al (2016) Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: a cost-utility analysis. J Shoulder Elbow Surg 25:704–713. https://doi.org/10.1016/j.jse.2015.12.022CrossRefPubMed

28.

Röderer G, Gebhard F, Krischak G et al (2011) Biomechanical in vitro assessment of fixed angle plating using a new concept of locking for the treatment of osteoporotic proximal humerus fractures. Int Orthop 35:535–541. https://doi.org/10.1007/s00264-010-1021-9CrossRefPubMed

29.

Jost B, Spross C, Grehn H, Gerber C (2013) Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg 22:542–549. https://doi.org/10.1016/j.jse.2012.06.008CrossRefPubMed

Title: Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands
Authors: Arie Greenberg
Philip J. Rosinsky
Nir Gafni
Yona Kosashvili
Alexander Kaban
Publication date: 01-05-2021
Publisher: Springer Paris
Published in: European Journal of Orthopaedic Surgery & Traumatology / Issue 4/2021
Print ISSN: 1633-8065
Electronic ISSN: 1432-1068
DOI: https://doi.org/10.1007/s00590-020-02832-x

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Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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