Functional outcomes of minimal invasive percutaneous plate osteosynthesis (MIPPO) in humerus shaft fractures: a clinical study

Abstract

Objective: We aimed to evaluate the objective and subjective outcomes of humerus shaft fractures treated with minimal invasive percutaneous plate osteosynthesis and emphasize points which may enhance clinical outcomes and simplify the procedure.

Methods: The retrospective study included 14 patients (mean age: 41.7 years; range: 19 to 66 years) with humerus mid-shaft fractures treated with the MIPPO technique between 2009 and 2011. 4.5-mm locking plates were applied via an anterior approach and advanced antegradely (proximal to distal) to protect the integrity of the deltoid insertion. Fracture healing was evaluated using plain radiographs. Objective outcomes were assessed in terms of range of motion and subjective outcomes using the American Shoulder and Elbow Society (ASES), University of California, Los Angles (UCLA), Mayo Elbow Performance Index (MEPI) and The Disability of The Arm, Shoulder and Hand (DASH) scores.

Results: Satisfactory outcomes with successful union were obtained within a mean of 17.8 (range: 13 to 30) months. While the average active forward flexion of shoulder was 163.9°±5.6°, the mean abduction was 87.8°±3.77°. Mean elbow flexion and extension loss was 134.6°±41.16° and 3.9°±6.25°, respectively. Mean ASES and UCLA scores were 90.2±4.76 and 31.8±1.56 and mean MEPI and DASH score were 93.6±4.12 and 4.6±2.19, respectively.

Conclusion: Minimal invasive percutaneous plate osteosynthesis appears to be a successful technique for the treatment of humerus shaft fractures. The procedure may be simplified and outcomes improved by engaging the plate with the anterior surface of the humerus during advancement, antegrade advancement of the plate to protect deltoid insertion and using of a minimum of 6 cortices for each side of the fracture to provide stable fixation.

Keywords

• Fracture
• humerus shaft
• MIPPO

Humerus şaft kırıklarında minimal invaziv perkütan plak osteosentezinin (MIPPO) fonksiyonel sonuçları: Klinik çalışma

Abstract

Amaç: Çalışmamızda minimal invaziv perkütan plak osteosentezi (MİPPO) ile tedavi edilmiş humerus şaft kırıklarında hem objektif hem de sübjektif sonuçların tartışılmasını ve klinik sonuçları iyileştirecek ve prosedürü kolaylaştıracak noktaların tartışılmasını amaçladık.

Çalışma planı: Bu retrospektif çalışmaya 2009-2011 yılları arasında MİPPO tekniği ile tedavi edilmiş 14 humerus orta şaft kırığı dahil edildi. Hastaların ortalama yaşı 41.7 (dağılım: 19-66) idi. 4.5 mm’lik kilitli plaklar anterior yaklaşım ile deltoid yapışma yerinin bütünlüğünü korumak için antegrad olarak (proksimalden distale) ilerletilerek uygulandı. Kırık iyileşmesi düz radyografiler ile değerlendirildi. Objektif sonuçlar eklem hareket açıklığı, sübjektif sonuçlar ise ASES, UCLA, MEPI ve DASH skorları ile değerlendirildi.

Bulgular: Başarılı kaynamanın görüldüğü tatmin edici sonuçlar ortalama 17.8 (dağılım: 13-30) ayda elde edildi. Omuzun ortalama aktif öne fleksiyonu 163.9°±5.6° iken, ortalama abdüksiyon 87.8°±3.77° idi. Ortalama dirsek fleksiyonu ve ekstansiyon kaybı, sırasıyla, 134.6°±41.16° ve 3.9°±6.25° idi. Ortalama ASES ve UCLA skorları 90.2±4.76 ve 31.8±1.56 olarak ölçülürken, ortalama MEPI ve DASH skoru 93.6±4.12 ve 4.6±2.19 olarak kaydedildi.

Çıkarımlar: Minimal invaziv perkütan plak osteosentezi humerus şaft kırıklarının tedavisinde başarılı bir tekniktir. Plağın ilerletilmesi sırasında plağın humerus anterior yüzü ile temas halinde olması, deltoid yapışma yerinin korunması için plağın antegrad ilerletilmesi ve kırık hattının her iki tarafında en az altı korteks ile stabil tespitin yapılması prosedürü basitleştirecek ve sonuçları iyileştireceğini düşündüğümüz unsurlardır.

Keywords

• Humerus şaft; kırık; MİPPO.

References

1. Igbigbi PS, Manda K. Epidemiology of humeral fractures in Malawi. Int Orthop 2004;28:338-41.
2. Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998;80:249-53.
3. Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. The Holstein-Lewis humeral shaft fracture: aspects of radial nerve injury, primary treatment, and outcome. J Orthop Trauma 2008;22:693-7.
4. Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Järvinen MJ. Functional treatment of closed humeral shaft fractures. Int Orthop 2005;29:10-3.
5. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478
6. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 2002;84:1093-110.
7. Yang KH. Helical plate fixation for treatment of comminuted fractures of the proximal and middle one-third of the humerus. Injury 2005;36:75-80.
8. Ziran BH, Belangero W, Livani B, Pesantez R. Percutaneous plating of the humerus with locked plating: technique and case report. J Trauma 2007;63:205-10.

9. Lin J, Hou SM. Locked nailing of severely comminuted or segmental humeral fractures. Clin Orthop Relat Res 2003;406:195-204.
10. Lau TW, Leung F, Chan CF, Chow SP. Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture. Int Orthop 2007;31:657-64.
11. Zhiquan A, Bingfang Z, Yeming W, Chi Z, Peiyan H. Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures. J Orthop Trauma 2007;21:628-33.
12. Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report. Injury 2005;36:530-8.
13. Kobayashi M, Watanabe Y, Matsushita T. Early full range of shoulder and elbow motion is possible after minimally invasive plate osteosynthesis for humeral shaft fractures. J Orthop Trauma 2010;24:212-6.
14. Ji F, Tong D, Tang H, Cai X, Zhang Q, Li J, Wang Q. Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique applied in the treatment of humeral shaft distal fractures through a lateral approach. Int Orthop 2009;33:543-7.
15. Livani B, Belangero WD. Bridging plate osteosynthesis of humeral shaft fractures. Injury 2004;35:587-95.
16. Klepps S, Auerbach J, Calhon O, Lin J, Cleeman E, Flatow E. A cadaveric study on the anatomy of the deltoid insertion and its relationship to the deltopectoral approach to the proximal humerus. J Shoulder Elbow Surg 2004;13:322-7.
17. López-Arévalo R, de Llano-Temboury AQ, SerranoMontilla J, de Llano-Giménez EQ, Fernández-Medina JM. Treatment of diaphyseal humeral fractures with the minimally invasive percutaneous plate (MIPPO) technique: a cadaveric study and clinical results. J Orthop Trauma 2011;25:294-9.
18. Jiang R, Luo CF, Zeng BF, Mei GH. Minimally invasive plating for complex humeral shaft fractures. Arch Orthop Trauma Surg 2007;127:531-5.
19. Aksu N, Karaca S, Kara AN, Işiklar ZU. Minimally invasive plate osteosynthesis (MIPO) in diaphyseal humerus and proximal humerus fractures. Acta Orthop Traumatol Turc 2012;46:154-60.
20. Apivatthakakul T, Patiyasikan S, Luevitoonvechkit S. Danger zone for locking screw placement in minimally invasive plate osteosynthesis (MIPO) of humeral shaft fractures: a cadaveric study. Injury 2010;41:169-72.
21. Gardner MJ, Griffith MH, Lorich DG. Helical plating of the proximal humerus. Injury 2005;36:1197-200.
22. Groh GI, Simoni M, Rolla P, Rockwood CA. Loss of the deltoid after shoulder operations: An operative disaster. J Shoulder Elbow Surg 1994;3:243-53.
23. Sher JS, Iannotti JP, Warner JJ, Groff Y, Williams GR. Surgical treatment of postoperative deltoid origin disruption. Clin Orthop Relat Res 1997;343:93-8.
24. Stoffel K, Dieter U, Stachowiak G, Gächter A, Kuster MS. Biomechanical testing of the LCP-how can stability in locked internal fixators be controlled? Injury 2003;34 Suppl 2:B11-9.