Use of different devices for surgical treatment of proximal humerus fractures in adults: a systematic review

Main Article Content

Vito Pavone
Andrea Vescio
Regina Denaro
Danilo Costa
Giuseppe Condorelli
Vincenzo Fabrizio Caruso
Giuseppe Sessa
Gianluca Testa

Keywords

Shoulder; ORIF; MIPO; Plate; Deltopectoral approach; Transdeltoid approach

Abstract

Background and aim: Proximal humeral fracture is one of the most common osteoporotic fractures in elderly people. The proper treatment choice is controversial. Open reduction and internal fixation (ORIF) with plate and screws is currently the most common treatment for the majority of displaced proximal humeral fractures. The aim of this systematic review is to investigate the surgical treatment outcomes of PHFs, focusing on main used devices and surgical approaches.


Methods: From the earliest record up to 21 July 2020, two independent authors conducted a systematic review of two medical electronic database (PubMed and Science Direct). To achieve the maximum sensitivity of the search strategy, the following terms were combined: “(proximal NOT shaft NOT distal) AND humeral AND fracture AND (plate OR locking plate OR osteosynthesis NOT nail NOT arthroplasty)” as either key words or MeSH terms. The risk of bias of the included studies was assessed, agreeing to the Cochrane Handbook guidelines.


Results: Thirty-four articles were initially noticed after the term string research in the two electronic databases. Finally, after full-text reading and analyzing the reference list, 8 studies were selected. The mean age recorded was 69.5 years (Range 67-72). All the studies included two-, three-, four-fragments fracture. Seven studies investigated PHILOS (Synthes, Bettlach, Switzerland) implants results, while one investigated CFR-PEEK plate (PEEK Power Humeral Fracture Plate; Arthrex, Naples, Florida, USA) outcomes or other plates. Deltopectoral and Transdeltoid approaches were the more common used.


Conclusions: Both deltopectoral and transdeltoid approaches are valid approach in plating after proximal humerus fractures, for these reasons, the surgeon experience is crucial in the choice. The more valid implant is still unclear. The develop of prospective randomized comparative studies is strongly encourages.

Abstract 959 | PDF Downloads 656

References

1. Chen X, Yu ZX, Wang HY, et al. Proximal humeral internal locking plate combined with a custom neutral-position shoulder and elbow sling for proximal humerus fractures: A randomized study. Medicine (Baltimore) 2019; 98 (17): e15271.
2. Bockmann B, Lechler P, Boese CK, Aigner R, Ruchholtz S, Frink M. Risk factors for secondary displacement in conservatively treated isolated greater tuberosity fractures: An analysis of 82 cases. Orthop Traumatol Surg Res 2019;105 (2): 317-22.
3. Brorson S, Eckardt H, Audigé L, Rolauffs B, Bahrs C. Translation between the Neer- and the AO/OTA-classification for proximal humeral fractures: do we need to be bilingual to interpret the scientific literature? BMC Res Notes 2013; 6: 69.
4. Papakonstantinou MK, Hart MJ, Farrugia R, et al. Interobserver agreement of Neer and AO classifications for proximal humeral fractures. ANZ J Surg 2016; 86 (4): 280-4.
5. Majed A, Macleod I, Bull AM, et al. Proximal humeral fracture classification systems revisited. J Shoulder Elbow Surg 2011; 20 (7): 1125-32.
6. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011; 20 (5): 747-55.
7. Li Y, Zhao L, Zhu L, Li J, Chen A. Internal fixation versus nonoperative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients: a meta-analysis of randomized controlled trials. PLoS One 2013; 8 (9): e75464.
8. Ge W, Sun Q, Li G, Lu G, Cai M, Li S. Efficacy comparison of intramedullary nails, locking plates and conservative treatment for displaced proximal humeral fractures in the elderly. Clin Interv Aging 2017; 12: 2047-54.
9. Sohn HS, Jeon YS, Lee J, Shin SJ. Clinical comparison between open plating and minimally invasive plate osteosynthesis for displaced proximal humeral fractures: A prospective randomized controlled trial. Injury 2017; 48 (6): 1175-82.
10. Röderer G, Gebhard F, Krischak G, Wilke HJ, Claes L. Biomechanical in vitro assessment of fixed angle plating using a new concept of locking for the treatment of osteoporotic proximal humerus fractures. Int Orthop 2011;35 (4): 535-41.
11. Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res 2014; 472 (5): 1576-85.
12. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (7): e1000097.
13. Xu C, Liu TZ, Jia PL, et al. Improving the quality of reporting of systematic reviews of dose-response meta-analyses: a cross-sectional survey. BMC Med Res Methodol 2018;18 (1): 157.
14. Ziegler P, Maier S, Stöckle U, Gühring M, Stuby FM. The Treatment of Proximal Humerus Fracture Using Internal Fixation with Fixed-angle Plates. Dtsch Arztebl Int 2019; 116 (45): 757-63.
15. Liu ZZ, Zhang GM, Ge T. Use of a proximal humeral internal locking system enhanced by injectable graft for minimally invasive treatment of osteoporotic proximal humeral fractures in elderly patients. Orthop Surg 2011; 3 (4): 253-8.
16. Voigt C, Geisler A, Hepp P, Schulz AP, Lill H. Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma 2011;25 (10): 596-602.
17. Fjalestad T, Hole MØ, Hovden IA, Blücher J, Strømsøe K. Surgical treatment with an angular stable plate for comJplex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma 2012;26 (2): 98-106.
18. Zhao L, Yang P, Zhu L, Chen AM. Minimal invasive percutaneous plate osteosynthesis (MIPPO) through deltoid-pectoralis approach for the treatment of elderly proximal humeral fractures. BMC Musculoskelet Disord 2017; 18 (1): 187.
19. Bockmann B, Buecking B, Franz D, Zettl R, Ruchholtz S, Mohr J. Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study. BMC Musculoskelet Disord 2015; 16: 160.
20. Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 2015; 313 (10): 1037-47.
21. Launonen AP, Sumrein BO, Reito A, et al. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med 2019; 16 (7): e1002855.
22. Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J 2017; 99-B (3): 383-92.
23. Duralde XA. CORR Insights®: Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res 2014; 472 (5): 1586-8.
24. Martetschläger F, Siebenlist S, Weier M, et al. Plating of proximal humeral fractures. Orthopedics 2012; 35 (11): e1606-12.
25. Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2015; 11: CD000434.
26. Egol KA, Kubiak EN, Fulkerson E, Kummer FJ, Koval KJ. Biomechanics of locked plates and screws. J Orthop Trauma 2004; 18 (8): 488-93.
27. Kubiak EN, Fulkerson E, Strauss E, Egol KA. The evolution of locked plates. J Bone Joint Surg Am 2006; 88 (4):189-200.
28. Seide K, Triebe J, Faschingbauer M, et al. Locked vs. unlocked plate osteosynthesis of the proximal humerus - a biomechanical study. Clin Biomech (Bristol, Avon) 2007; 22 (2): 176-182.
29. Gillespie RJ, Ramachandran V, Lea ES, Vallier HA. Biomechanical evaluation of 3-part proximal humerus fractures: a cadaveric study. Orthopedics 2009; 32 (11): 816.
30. Zettl R, Müller T, Topp T, et al. Monoaxial versus polyaxial locking systems: a biomechanical analysis of different locking systems for the fixation of proximal humeral fractures. Int Orthop 2011; 35 (8): 1245-50.
31. Erhardt JB, Stoffel K, Kampshoff J, Badur N, Yates P, Kuster MS. The position and number of screws influence screw perforation of the humeral head in modern locking plates: a cadaver study. J Orthop Trauma 2012; 26 (10): e188-92.
32. Ockert B, Pedersen V, Geyer L, Wirth S, Mutschler W, Grote S. Position of polyaxial versus monoaxial screws in locked plating for proximal humeral fractures: analysis of a prospective randomized study. Eur J Orthop Surg Traumatol 2014; 24 (5): 747-52.