Humerus head osteonecrosis in surgical treatment intraarticular fractures of proximal humerus by PHILOS plate

Česká verzia

Authors: Radek Pikula; Daniel Ira; Milan Krtička; Michal Mašek; Petr Nestrojil
Authors place of work: Oddělení dětské onkologie FN Brno ; Tramacentrum FN Brno
Published in the journal: Úraz chir. 21., 2013, č.3

Summary

INTRODUCTION:
Intra-articular humeral head fractures face a high risk of humeral head osteonecrosis development. Reduced bone quality in the area of humeral head and osteoporosis in older patients limit the options of successful osteosynthesis.

MATERIAL AND METHODS:
A total of twenty-nine patients with intra-articular proximal humerus fractures treated surgically by LCP plate (PHILOS^®) at our department from 2009 to 2013 were included in our study. All patients underwent X-ray and CT examination and the fractures were classified according to the AO classifiication. Predictors of the humeral head ischemia defined by Hertel in 2004 (length of the metaphyseal calcar segment less than 8 mm, disruption of the medial hinge, fractures of the anatomical neck, four-fragments fractures, head angulation over 45 degrees, displacement of tuberosities over 10 mm, glenohumeral dislocation and head-split component) were used for further assessment of patients with humeral head osteonecrosis (partial or complete).

RESULTS:
Humeral head osteonecrosis occurred in 10 out of 29 cases (34.5 %). Complete head osteonecrosis with the collapse and resorption was noted only in 1 case (3.4 %). C3 fractures were affected by osteonecrosis in 55.6 % of cases, C2 fractures in 27.8 %. No avascular necrosis was noted in the C1 fracture group. Predictors of humeral head ischemia, i.e. length of the metaphyseal calcar segment less than 8mm, disruption of the medial hinge, fractures of the anatomical neck and four-fragments fracture were found in the case of complete humeral head osteonecrosis. Most of the predictors (70-100%) have occurred in fractures with developed partial head osteonecrosis.

CONCLUSION:
The risk of osteonecrosis is considerably higher in C type fractures. Patients with humeral head osteonecrosis reached a significantly worse functional outcome and required more revision operations. Evaluation of humeral head ischemia predictors is important for the prognosis of fracture healing and for assessing the risk of head osteonecrosis. Fractures with highly predictable humeral head necrosis should be considered for primary hemiarthroplasty.

Key words:
osteonecrosis, PHILOS plate, screw cut-out, predictors of humeral head ischemia.

Zdroje

1. BARTONÍČEK, J., HEŘT, J. Základy klinické anatomie pohybového aparátu. Praha: Maxdorf s.r.o. 2004, 256 s.

2. BASTIAN, J.D., HERTEL, R. Initial postfracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg. 2008, 17, 2–8.

3. BOILEAU, P., TROJANI, C., WALCH, G. et al. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg. 2001, 10, 288–308.

4. BOISSONNAULT, W.G. Joint and muscle disorders. In: GOODMAN, C.C., BOISSONNAULT, W.G. Pathology: Implications for the Physical Therapist. Philadelphia, PA: W. B. Saunders Company, 1998.

5. CONSTANT, C.R., MURLEY, A.H. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987, 214, 160–164.

6. CRUESS, R.L. Osteonecrosis of bone. Current concepts as to etiology and pathogenesis. Clin Orthop Relat Res. 1986, 208, 30–39.

7. DINES, D.M. et al. Posttraumatic changes ofthe proximal humerus: malunion, nonunion and osteonecrosis: treatment with modular hemiarthroplasty of the total shoulder athroplasty. J Shoulder Elbow Surg. 1993, 2, 11–21.

8. GARDNER, M. Indirect Medial Reduction and Strut Support of Proximal Humerus Fractures Using an Endosteal Implant. J Orthop Trauma. 2008, 22, 3.

9. GERBER, C., LANBERT, S.M. Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am. 1996, 78A, 376–382.

10. HEINMANN, W.G., FREIBERGER, R.H. Avascular Necrosis of the Femoral and Humeral Heads after High-Dosage Corticosteroid Therapy. N Engl J Med.1960, 263, 672–675.

11. HERTEL, R. Fractures of the proximal humerus in osteoporotic bone. Osteoporosis In. 2005, 16, S65–572.

12. HERTEL, R., HEMPFING, A., STIEHLER, M. et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004, 13, 427–433.

13. JAEGER, M., LEUNG, F., LI, W. AO Surgery Reference. Müller AO Classification of Fractures – Proximal Humerus. https://www2.aofoundation.org/wps/portal/surgery?show Page =diagnosis&bone=Humerus&segment=Proximal. 2007

14. KŘIVOHLÁVEK, M., LUKÁŠ, S., TALLER, J. et al. Použití úhlově stabilních implantátů při ošetření zlomenin proximálního humeru – prospektivní studie. Acta Chir Orthop Traumatol Čech. 2008, 75, 212–220.

15. KULKARNI, R.R., NANDEDKAR, A.N., MYSOREKAR, V.R. Position of the axillary nerve inthe deltoid muscle. Anat Rec. 1992, 232, 316–317.

16. LILL, H., HEPP, P., GOWIN, W. et al. RoFo: Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin. 2002, 174, 1544–1550.

17. LUKÁČ, L., PLEVA, L., MADEJA, R. Možnosti využití reverzní TEP ramenního kloubu v úrazové chirurgii Úraz chir. 2007, 15, 114–118.

18. NAMDARI, S., VOLETI, P.B., MEHTA, S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012, 21, 1787–1795.

19. OSTRUM, R.F., CHAO, E.Y.S., BASSET, C.A.L. et al. Bone injury, regeneration, and repair. In: SIMON, S.R. Orthopaedic Basic Science. Rosemont, IL: AAOS, 1994.

20. ROCKWOOD, C.A., BUCHOLZ, R.W., COURT-BROWN, C. et al. Rockwood and Green‘s Fractures in Adults. 2009.

21. SPROSS, C., PLATZ, A., RUFIBACH, K. et al. The PHILOS plate for proximal humeral fractures-risk factors for complications at one year. J Trauma Acute Care Surg. 2012, 72, 783–792.

22. TINGART, M.J., LEHTINEN, J., ZUKAROWSKI, D. et al. Proximal humerus fractures: Regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws. J Shoulder Elbow Surg. 2006, 15, 5.

23. WIJGMAN, A.J., ROOLKER, W., PATT, T.W. 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, 84A, 1919–1925.