Top

Archives of Orthopaedic and Trauma Surgery

Published in:

01-12-2011 | Orthopaedic Surgery

Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant

Authors: Andrew S. Neviaser, Carolyn M. Hettrich, Joshua S. Dines, Dean G. Lorich

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 12/2011

Abstract

Introduction

Treatment of displaced proximal humerus fractures remains challenging. The introduction of locking plates has renewed interest in treating these fractures with joint-preserving techniques rather than hemiarthroplasty, but high complication rates are still reported. Avascular necrosis is not solely dependent on the initial fracture pattern, but can also result from intraoperative and postoperative vascular insults.

Method

We describe a technique to minimize disruption of humeral head blood supply and maximize fracture fixation. A total of 34 patients with complex proximal humerus fractures were treated with a locking plate and endosteal implant through an anterolateral approach and followed for an average of 66 weeks to determine the rates of avascular necrosis.

Results

No patient suffered complete osteonecrosis (0%) and only one patient suffered partial necrosis (2.8%) of the humeral head. The length of the posteromedial hinge was not predictive of this complication.

Conclusion

Use of the anterolateral approach and endosteal augment of a lateral locking plate can minimize avascular necrosis following proximal humerus fracture.

Agudelo J, Schurmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W (2007) Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 21:676–681. doi:10.1097/BOT.0b013e31815bb09d PubMedCrossRef

Bastian JD, Hertel R (2008) Initial post-fracture humeral head ischemia does not predict development of necrosis. J Should Elb Surg 17:2–8. doi:10.1016/j.jse.2007.03.026 CrossRef

Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audige L, Babst R (2009) Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma 23(3):163–172. doi:10.1097/BOT.0b013e3181920e5b PubMedCrossRef

Court-Brown CM, Garg A, McQueen MM (2001) The epidemiology of proximal humeral fractures. Acta Orthop Scand 72:365–371. doi:10.1080/000164701753542023 PubMedCrossRef

Crosby LA, Finnan RP, Anderson CG, Gozdanovic J, Miller MW (2009) Tetracycline labeling as a measure of humeral head viability after 3- or 4-part proximal humerus fracture. J Should Elb Surg 18(6):851–858. doi:10.1016/j.jse.2008.12.016 CrossRef

Duparc F, Muller JM, Freger P (2001) Arterial blood supply of the proximal humeral epiphysis. Surg Radiol Anat 23(3):185–190PubMedCrossRef

Edelson G, Safuri H, Salami J, Vigder F, Militianu D (2008) Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Should Elb Surg 17:399–409. doi:10.1016/j.jse.2007.08.014 CrossRef

Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R (2005) A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 430:176–181PubMedCrossRef

Gardner MJ, Boraiah S, Helfet DL, Lorich DG (2008) Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 22(3):195–200. doi:10.1097/BOT.0b013e31815b3922 PubMedCrossRef

10.

Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG (2007) The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 21(3):185–191. doi:10.1097/BOT.0b013e3180333094 PubMedCrossRef

11.

Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG (2006) Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma 20:602–607. doi:10.1097/01.bot.0000246412.10176.14 PubMedCrossRef

12.

Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG (2005) The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res 434:123–129PubMedCrossRef

13.

Gerber C, Werner CM, Vienne P (2004) Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br 86:848–855PubMedCrossRef

14.

Gerber C, Hersche O, Berberat C (1998) The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Should Elb Surg 7(6):586–590CrossRef

15.

Gerber C, Schneeberger AG, Vinh TS (1990) The arterial vascularization of the humeral head. An anatomical study. J Bone Jt Surg Am 72:1486–1494

16.

Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H (2008) The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. J Should Elb Surg 17(1):21–28. doi:10.1016/j.jse.2007.03.029 CrossRef

17.

Hertel R, Hempfing A, Stiehler M, Leunig M (2004) Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Should Elb Surg 13(4):427–433. doi:10.1016/S1058274604000795 CrossRef

18.

Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG (2010) Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Jt Surg Am 92(4):943–948. doi:10.2106/JBJS.H.01144 CrossRef

19.

Lee CK, Hansen HR (1981) Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures. J Trauma 21(9):788–791PubMedCrossRef

20.

Lee CW, Shin SJ (2009) Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation. J Should Elb Surg 18:83–88. doi:10.1016/j.jse.2008.06.014 CrossRef

21.

Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M (2010) Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech (Bristol, Avon) 25:642–646. doi:10.1016/j.clinbiomech.2010.04.006 CrossRef

22.

Owsley KC, Gorczyca JT (2008) Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Jt Surg Am 90:233–240. doi:10.2106/JBJS.F.01351 CrossRef

23.

Rose PS, Adams CR, Torchia ME, Jacofsky DJ, Haidukewych GG, Steinmann SP (2007) Locking plate fixation for proximal humeral fractures: initial results with a new implant. J Should Elb Surg 16(2):202–207. doi:10.1016/j.jse.2006.06.006 CrossRef

24.

Solberg BD, Moon CN, Franco DP, Paiement GD (2009) Surgical treatment of three and four-part proximal humeral fractures. J Bone Jt Surg Am 91(7):1689–1697. doi:10.2106/JBJS.H.00133 CrossRef

25.

Solberg BD, Moon CN, Franco DP, Paiement GD (2009) Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma 23(2):113–119. doi:10.1097/BOT.0b013e31819344bf PubMedCrossRef

26.

Sudkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kaab M, Luo C, Plecko M, Wendt K, Kostler W, Konrad G (2009) Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Jt Surg Am 91:1320–1328. doi:10.2106/JBJS.H.00006

27.

Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P (2009) Treatment of proximal humerus fractures with locking plates: a systematic review. J Should Elb Surg 18:612–621. doi:10.1016/j.jse.2009.06.004 CrossRef

28.

Young TB, Wallace WA (1985) Conservative treatment of fractures and fracture-dislocations of the upper end of the humerus. J Bone Jt Surg Br 67:373–377

Title: Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant
Authors: Andrew S. Neviaser
Carolyn M. Hettrich
Joshua S. Dines
Dean G. Lorich
Publication date: 01-12-2011
Publisher: Springer-Verlag
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 12/2011
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-011-1366-6

At a glance: The STEP trials

Springer Medicine

Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant

Abstract

Introduction

Method

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Method

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 12/2011

Technique for intraoperative determination of femoral rotation with a lateral femur nail (LFN, Synthes, Oberdorf, Switzerland)

Reconstruction with modular hemipelvic prosthesis for the resection of solitary periacetabular metastasis

Results of the Total Evolutive Shoulder System (TESS®): a single-centre study of 56 consecutive patients

Outcome assessment in hip fracture: evaluation of the practicality of commonly-used outcomes in hip fracture studies

Biomechanics of vertebral compression fractures and clinical application

Above- or below-elbow casts for distal third forearm fractures in children? A meta-analysis of the literature