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Surgical Treatment of Three and Four-Part Proximal Humeral Fractures
Brian D. Solberg, MD1; Charles N. Moon, MD2; Dennis P. Franco, MD2; Guy D. Paiement, MD2
1 1414 South Grand Avenue, Suite 123, Los Angeles, CA 90015. E-mail address: brian@briansolbergmd.com
2 Cedars Sinai Medical Center, 444 South San Vicente Boulevard, Suite 603, Los Angeles, CA 90048. E-mail address for C.N. Moon: charles.moon@cshs.org. E-mail address for D.P. Franco: dennis.franco@cshs.org. E-mail address for G.D. Paiement: guy.paiement@cshs.org
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Cedars Sinai Medical Center, Los Angeles, California

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Jul 01;91(7):1689-1697. doi: 10.2106/JBJS.H.00133
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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. Fixed-angle locked plates that maintain angular stability under load have been proposed as an alternative to hemiarthroplasty for the treatment of some osteoporotic fracture types.

Methods: The records of 122 consecutive patients who were fifty-five years of age or older and in whom a Neer three or four-part proximal humeral fracture had been treated surgically between January 2002 and November 2005 were studied retrospectively. After exclusions, thirty-eight patients treated with a locked-plate construct were compared with forty-eight patients who had undergone hemiarthroplasty. All patients had radiographic and clinical follow-up at a minimum of twenty-four months and an average of thirty-six months. Reduction and implant placement were evaluated radiographically. Clinical outcomes were measured with use of the Constant-Murley system.

Results: The mean Constant score (and standard deviation) at the time of final follow-up was significantly better in the locked-plate group (68.6 ± 9.5 points) than in the hemiarthroplasty group (60.6 ± 5.9 points) (p < 0.001). The Constant scores for the three-part fractures in the locked-plate and hemiarthroplasty groups were 71.6 and 60.4 points (p < 0.001), respectively, and the scores for the four-part fractures in those groups were 64.7 and 60.1 points (p = 0.19), respectively. Patients with an initial varus extension deformity in the locked-plate group had significantly worse outcomes than those with a valgus impacted pattern (Constant score, 63.8 compared with 74.6 points, respectively; p < 0.001). Complications in the group treated with locked-plate fixation included osteonecrosis in six patients, screw perforation of the humeral head in six patients, loss of fixation in four patients, and wound infection in three patients. Loss of fixation was seen only in patients with >20° of initial varus angulation of the humeral head. Complications in the hemiarthroplasty group included nonunion of the tuberosity in seven patients and wound infection in three patients.

Conclusions: In this series, open repair with use of a locked plate resulted in better outcome scores than did hemiarthroplasty in similar patients, especially in those with a three-part fracture, despite a higher overall complication rate. Open reduction and internal fixation of fractures with an initial varus extension pattern should be approached with caution.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Brian D. Solberg, MD
    Posted on August 25, 2009
    Dr. Solberg and colleagues respond to Mr. Clarke and Mr. Nunn
    NULL

    Thank you for your inquiry which raises several valid points regarding our analysis of these injuries.

    The first question pertains to the severity of the fracture patterns we triaged to each group and the bias this introduced into the data analysis. As the question indicates, there is no Level 1 data regarding the management of these injuries so most series are based on commonly accepted treatment protocols with retrospective data analysis. In our series, all patients were over 55 years of age and the vast majority of the fractures in both groups were secondary to trip and fall injuries. In that regard, the two groups were similar. Of the 71 patients in the hemiarthroplasty group prior to exclusion, 37 had a ‘head split’ pattern, 17 had anatomic neck displacement of greater than 2 cm, 9 had impaction of the articular surface and 6 were dislocated for more than 24 hours. Whether the above patterns represent more severe injuries in this population remains unanswered but these patterns are not thoroughly addressed in Neer’s original classification (1). However, all patients with a documented rotator cuff tear were excluded from the final study groups so there was no bias introduced by this variable.

    The second question pertains to the overall respective complication rates of hemiarthroplasty and ORIF. We struggled with this question as the number of possible complications is very large. For example, should humeral head osteonecrosis be considered a complication of the injury or the treatment of the injury? Should asymptomatic osteonecrosis be considered a complication of locked plate treatment? Since this complication cannot happen in the hemiarthroplasty group, should it be compared? In the ORIF group, there were 3 infections (8%), 6 head perforations (16%) and 4 patients with loss of fixation (12%). There was some overlap and the above complications were observed in 11/38 patients (29%). In the hemiarthroplasty group, three patients developed a wound infection (6%), and seven (15%) developed a tuberosity nonunion with an overall complication rate of 10/48 (21%). Our series did not have the statistical power to discern between these two groups (p=0.18). A post-hoc analysis indicated that we would need 85 patients in each group to achieve statistical significance assuming that an 8% difference in complication rates was real. Furthermore, the rate of iatrogenic complications such as screw perforation and loss of fixation decreased over time as our intra-operative technique for evaluating implant position and humeral head reduction improved. In examining the complications within the ORIF group, the rate of complication in the valgus patterns was 4/26 (15%) vs. 7/12 (58%) in the varus patterns (p=0.04). This is consistent with previously published data indicating that the complication rate is more a function of initial fracture pattern than the severity using the Neer classification (2).

    The purpose of our series was not to compare hemiarthroplasty to ORIF across the board but to identify fracture patterns which can have better outcomes with ORIF and identify which ones yielded equivocal outcomes to hemiarthroplasty in a similar cohort of patients. The evidence presented this paper, although not definitive, robustly supports the use of a locked plate in many 3-part and 4-part fractures. What was definitive was that patients with initial valgus displacement had better outcomes and lower complication rates irrespective of Neer fracture type while varus fracture patterns had a higher complication rate and equivocal outcomes compared to hemiarthroplasty, an observation that has been documented previously in the literature (3). As we referenced in the manuscript, classifying these injuries based on the Neer or OTA systems was difficult as reported by other authors (4), however, neither one takes initial humeral head displacement into consideration. In our series, this was the singlemost important criterion influencing final outcome.

    References

    1. Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52:1090-103.

    2. Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: The effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23:113-9.

    3. Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73:295-8.

    4. Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75:1751-5.

    Jon V. Clarke
    Posted on August 10, 2009
    Surgical Treatment of Three and Four-Part Proximal Humeral Fractures
    West of Scotland Orthopaedic Rotation, United Kingdom

    To the Editor:

    We read with interest the article by Solberg et al. (1) which highlights the challenges of managing a complex fracture pattern which often has poor outcomes regardless of treatment (2), particularly in osteoporotic bone. We appreciate that the authors acknowledged a number of limitations in this retrospective review, but feel some important issues have been overlooked.

    Firstly, the two study groups differed with respect to the severity of the fractures sustained. The more complex patterns, including intra-articular fractures and those with associated rotator cuff tears, underwent prosthetic replacement as they were deemed unsuitable for internal fixation. While the authors felt they were unable to correct for this potential bias, it would not have been unreasonable to exclude these patients given that hemiarthroplasty was considered the only surgical option in these cases. Subsequently do the authors feel this would then alter the statistically significant outcomes?

    Secondly, it is noted that overall complication rates in both treatment groups were high but those managed with locking plates appear higher. Statistical comparison with regard to this appears missing from the text and we question whether the authors feel this would be of value?

    As yet there is no level I evidence comparing prosthetic replacement with internal fixation for Neer 3- and 4-part fractures, possibly due to the relative rarity of this injury (3) and the subsequent difficulties in recruiting sufficient numbers of patients prospectively. In summary we merely wish to question whether the evidence presented in this paper is robust enough to conclude that locked plate fixation results in better outcomes than hemiarthroplasty.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009;91:1689-97.

    2. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001:72:365-71.

    3. Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br. 2006;88:502-8.

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