Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk

Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk

Authors

  • Francesco Fazzari a:1:{s:5:"en_US";s:142:"Orthopaedics and Traumatology Unit, Cattinara Hospital, Department of Medical, Surgical and Life Sciences, Trieste University, Trieste (Italy)";}
  • Gianluca Canton
  • Gioia Giraldi
  • Nicholas Falcioni
  • Susanna Clocchiatti
  • Nicholas Rasio
  • Luigi Murena

Keywords:

proximal humerus fracture; avascular necrosis; complications; osteosynthesis; classification

Abstract

Background and aim: Avascular necrosis (AVN) of the humeral head is a relatively frequent complication after proximal humerus fractures (PHF). There are many factors related to the risk of developing AVN, with fracture complexity being one of the most relevant. Aim of the present study is to evaluate the correlation between different classification systems and the risk of post-operative AVN in patients treated with locking plate fixation for Neer 3 and 4-part PHFs.

Methods: The study population included 44 patients (F:M 2:1, mean age 62) treated between December 2014 and April 2019. Fractures were classified according to Neer, Russo and Lego classifications and Hertel’s criteria. AVN was established on postoperative radiographs after a minimum follow-up of 6 months. The odds ratio (OR) for AVN for each classification subtype was calculated.

Results: The incidence of necrosis was 11%. Significant association with AVN was found for Neer 4 part (OR=8), Russo IVB (OR=4), Lego pattern 12 (OR=8) and in presence of 3 mayor Hertel’s criteria (OR=15,5).

Conclusions: There is a significant association between AVN and Neer 4 part, Russo type IVB and Lego pattern 12 fractures. AVN risk is also significantly higher in presence of 3 major Hertel’s criteria.

References

(1) Passaretti D, Candela V, Sessa P, et al. Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area. J Shoulder Elbow Surg. 2017 Dec;26(12):2117-2124.

(2) Rouleau DM, Mutch J, Laflamme GY. Surgical Treatment of Displaced Greater Tuberosity Fractures of the Humerus. J Am Acad Orthop Surg. 2016 Jan;24(1):46-56.

(3) Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil. 2018 Jan 25;9:2151458517750516. doi: 10.1177/2151458517750516.

(4) Lambert SM. Ischaemia, healing and outcomes in proximal humeral fractures. EFORT Open Rev. 2018 May 21;3(5):304-315.

(5) Chen, Yx, Zhu, Y, Wu, Fh. et al. Anatomical study of simple landmarks for guiding the quick access to humeral circumflex arteries. BMC Surg 14, 39 (2014).

(6) Hettrich CM, Boraiah S, Dyke JP, et al. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am. 2010 Apr;92(4):943-8.

(7) Hertel R, Hempfing A, Stiehler M, et al. Predictors of proximal humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004; 13(4): 427–433. doi: 10.1016/S1058274604000795.

(8) Jakob RP, Miniaci A, Anson PS, et al. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991 Mar;73(2):295-8.

(9) Wijgman AJ, Roolker W, Patt TW, et al. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002 Nov;84(11):1919-25.

(10) Edelson G, Safuri H, Salami J, et al. Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg. 2008 May-Jun;17(3):399-409.

(11) Neer CS II. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elb Surg. 2002;11:389–400. doi: 10.1067/mse.2002.124346.

(12) Majed A, Macleod I, Bull AMJ, et al Proximal humeral fracture classification systems revisited J Shoulder Elbow Surg 2011 Oct;20(7):1125-32.

(13) Codman EA. The shoulder; rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston: Thomas Todd Company; 1934.

(14) Russo R, Cautiero F, Della Rotonda G,The classification of complex 4-part humeral fractures revisited: the missing fifth fragment and indications for surgery Musculoskelet Surg 2012 May;96 Suppl 1:S13-9.

(15) Murray IR, Amin AK, White TO, et al. Proximal humeral fractures: current concepts in classification, treatment and outcomes. J Bone Joint Surg Br. 2011 Jan;93(1):1-11.

(16) Maier D, Jajer M, Strohm PC, et al. Treatment of proximal humeral fractures - a review of current concepts enlightened by basic principles. Acta Chir Othop.et Traum. Čechosl 2012, p.307–16.

(17) Murena L, Canton G, Ratti C, et al. Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients. Orthop Rev (Pavia). 2020;12(1):8559. Published 2020 Apr 28. doi:10.4081/or.2020.8559

(18) Schnetzke M, Bockmeyer J, Porschke F, et al. Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures. J Bone Joint Surg Am. 2016 Nov 2;98(21):1777-1785.

(20) Cruess RL. The current status of avascular necrosis of the femoral head. Clin Orthop Relat Res 1978;131:309–11.

(21) Campochiaro G, Rebuzzi M, Baudi P, et al. Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis. Musculoskelet Surg. 2015 Sep;99 Suppl 1:S9-15.

(22) Fattoretto D, Borgo A, Iacobellis C. The treatment of complex proximal humeral fractures: analysis of the results of 55 cases treated with PHILOS plate. Musculoskelet Surg. 2016 Aug;100(2):109-14. (36) Beeres FJP, Hallensleben NDL, Rhemrev SJ, et al. Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications. Arch Orthop Trauma Surg. 2017 Dec;137(12):1685-1692.

(23) Sproul RC, Iyengar JJ, Devcic Z, et al. A systematic review of locking plate fixation of proximal humerus fractures. Injury 2011;42:408-13.

(24) Boesmueller S, Wech M, Gregori M, et al. Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures. Injury. 2016 Feb;47(2):350-5. doi: 10.1016/j.injury.2015.10.001. Epub 2015 Oct 22.

(25) Cai P, Yang Y, Xu Z, et al. Anatomic locking plates for complex proximal humeral fractures: anatomic neck fractures versus surgical neck fractures. J Shoulder Elbow Surg. 2019 Mar;28(3):476-482. doi: 10.1016/j.jse.2018.08.012.

(26) Greiner S, Kääb MJ, Haas NP, et al. Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures, Injury, Volume 40, Issue 2, 2009, Pages 186-191.

Downloads

Published

23-06-2023

How to Cite

1.
Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk. Acta Biomed [Internet]. 2023 Jun. 23 [cited 2024 Jun. 22];94(S2):e2023089. Available from: https://www.mattioli1885journals.com/index.php/actabiomedica/article/view/13871