Results of surgical management of valgus-impacted proximal humerus fractures with structural allografts

Yıl 2014, , 546 - 552, 12.11.2014

Ata Atalar İlker Eren Serkan Uludag Mehmet Demirhan

https://doi.org/10.3944/AOTT.2014.14.0115

Öz

Objective: The aim of this study was to clinically and radiologically evaluate patients treated with plate osteosynthesis with structural allografts for severely valgus-impacted fractures of the proximal humerus.

Methods: The study included 10 patients (average age: 57 years; range: 34 to 77 years) with valgus-impacted Neer Type 4 proximal humerus fractures. Fractures were classified according to the Robinson classification. Patients were called for an up-to-date examination and evaluated radiologically and clinically with Constant and DASH scores.

Results: Average follow-up period was 22.5±12.2 (range: 12 to 50) months. Average DASH score at the final follow-up was 7.6±4.5 (range: 2.5 to 16.7) and average Constant score was 87.7±4.4 (range: 83 to 94). None of the cases had early or late head collapse. There was no avascular necrosis. One early screw penetration was observed.

Conclusion: Surgical treatment of valgus-impacted proximal humerus fractures achieved successful results. However, the cavity under the humeral head may lead to failure due to mechanical insufficiency. Plate osteosynthesis with structural allografts warrants initial mechanical support until union, thus avoiding complications related to head collapse.

Anahtar Kelimeler

Proximal humerus fracture, structural allograft, valgus impaction

Valgus impakte proksimal humerus kırıklarında yapısal allogreft ile tedavi sonuçları

Öz

Amaç: Bu çalışmada yapısal allogreftlerle yapılan plak osteosentezi ile ileri derecede valgus impakte kırıkları üzerinde alınacak sonuçların klinik ve radyolojik açıdan değerlendirilmesi amaçlanmıştır.

Çalışma planı: Valgus impakte Neer Tip 4 proksimal humerus kırığı tanısı alan ve ortalama yaşı 57 (dağılım: 34-77) olan 10 hasta çalışmaya dahil edilerek, kırıkları Robinson sınıflamasına göre sınıflandı. Hastalar güncel muayeneleri için çağrıldı; Constant ve DASH skorları ile klinik ve radyolojik olarak değerlendirildiler.

Bulgular: Ortalama takip süresi 22.5±12.2 (dağılım: 12-50) ay olarak kaydedildi. Son kontrol sırasında ortalama DASH skoru 7.6±4.5 (dağılım: 2.5-16.7) ve Constant skoru 87.7±4.4 (dağılım: 83-94) olarak ölçüldü. Hastaların hiçbirinde erken ve geç baş çökmesi veya avasküler nekroz görülmedi. Bir hastada erken vida penetrasyonu saptandı.

Çıkarımlar: Valgus impakte kırıkların cerrahi tedavisi ile başarılı sonuçlar elde edilmiştir. Bununla birlikte, humerus başının altında ortaya çıkan kavite, mekanik yetersizlik nedeniyle başarısızlığa yol açabilir. Yapısal allogreftler ile yapılan plak osteosentezi, başlangıç aşamasından kaynamaya dek yeterli mekanik desteği sağlayarak, baş çökmesi ile ilişkili komplikasyonlar oluşmasına engel olmaktadır.

Anahtar Kelimeler

Proksimal humerus kırığı; valgus impaksiyonu; yapısal allogreft

Kaynakça

• Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001;72:365-71.
• Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg Br 2002;84:504-8.
• Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-89.
• 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.
• Robinson CM, Longino D, Murray IR, Duckworth AD. Proximal humerus fractures with valgus deformity of the humeral head: the spectrum of injury, clinical assessment and treatment. J Shoulder Elbow Surg 2010;19:1105-14.
• Mills HJ, Horne G. Fractures of the proximal humerus in adults. J Trauma 1985;25:801-5.
• Resch H, Povacz P, Fröhlich R, Wambacher M. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 1997;79:295-300.
• Magovern B, Ramsey ML. Percutaneous fixation of proximal humerus fractures. Orthop Clin North Am 2008;39:405-16.
• Atalar AC, Demirhan M, Uysal M, Seyahi A. Treatment of Neer type 4 impacted valgus fractures of the proximal humerus with open reduction, elevation, and grafting. Acta Orthop Traumatol Turc 2007;41:113-9.
• Sanders RJ, Thissen LG, Teepen JC, van Kampen A, Jaarsma RL. Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. J Shoulder Elbow Surg 2011;20:1118-24.
• Röderer G, Erhardt J, Graf M, Kinzl L, Gebhard F. Clinical results for minimally invasive locked plating of proximal humerus fractures. J Orthop Trauma 2010;24:400-6.
• Demirhan M. Factors affecting the results of hemiarthroplasty for proximal humerus fractures. [Article in Turkish] Acta Orthop Traumatol Turc 2000;34:463-74.
• Kralinger F, Schwaiger R, Wambacher M, Farrell E, Menth-Chiari W, Lajtai G, et al. Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multicentre study of 167 patients. J Bone Joint Surg Br 2004;86:217-9.
• Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. J Bone Joint Surg Am 2004;86-A Suppl 1(Pt 2):143-55.
• Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures. Results of operative treatment. J Bone Joint Surg Am 2003;85-A:1647-55.
• Resch H, Beck E, Bayley I. Reconstruction of the valgusimpacted humeral head fracture. J Shoulder Elbow Surg 1995;4:73-80.
• Yu KS, Chan PT, Lau SC, Cheng SK, Faan YS, Ngai WK. Internal fixation of valgus-impacted humeral head fractures using the screw-wiring technique. Int Orthop 2002;26:13-6.
• Aksu N, Göğüş A, Kara AN, Işiklar ZU. Complications encountered in proximal humerus fractures treated with locking plate fixation. Acta Orthop Traumatol Turc 2010;44:89-96.
• Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani NC, Zuckerman JD. Early complications in proximal humerus fractures (OTA Types 11) treated with locked plates. J Orthop Trauma 2008;22:159-64.
• Vandenbussche E, Peraldi P, Naouri JF, Rougereau G, Augereau B. Four part valgus impacted fractures of the upper extremity of humerus: ilium graft reconstruction. Apropos of 8 cases. [Article in French] Rev Chir Orthop Reparatrice Appar Mot 1996;82:658-62. [Abstract]
• Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br 1997;79:857
• Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4.
• Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma 2011;25:612-7.
• Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am 1990;72:1486-94.
• Warner JJP, Iannotti JP, Flatow EL, editors. Complex and Revision Problems in Shoulder Surgery, 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2005.
• Hausberger KH. Blood supply of intraarticular fractures of the humeral head: an anatomical and biomechanical study. In: Proceedings of the 14th Congress of the European Society for Shoulder and Elbow Surgery, Lisbon, 2000.
• Levine WN, Marra. G, Bigliani LU, editors. Fractures of the shoulder girdle. New York, NY: Marcel Dekker; 200 Resch H, Aschauer E, Povacz P, Ritter E. Closed reduction and fixation of articular fractures of the humeral head. Tech Shoulder Elbow Surg 2000;1:154-62.
• Wiss DA, editor. Master techniques in orthopaedic surgery: fractures. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2006.
• Kim DH, Rhim R, Li L, Martha J, Swaim BH, Banco RJ, et al. Prospective study of iliac crest bone graft harvest site pain and morbidity. Spine J 2009;9:886-92.
• Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br 2004;86:848-55.
• Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg 2012;21:741-8.
• Zhu L, Liu Y, Yang Z, Li H, Wang J, Zhao C, et al. Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture. Chin Med J (Engl) 2014;127:1672-6.
• Matassi F, Angeloni R, Carulli C, Civinini R, Di Bella L, Redl B, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury 2012;43:1939-42.
• Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 2005;430:176-81.
• Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma 2009;23:163-72.
• Walsh S, Reindl R, Harvey E, Berry G, Beckman L, Steffen T. Biomechanical comparison of a unique locking plate versus a standard plate for internal fixation of proximal humerus fractures in a cadaveric model. Clin Biomech (Bristol, Avon) 2006;21:1027-31.
• Lee CW, Shin SJ. Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation. J Shoulder Elbow Surg 2009;18:83-8.
• Erhardt JB, Roderer G, Grob K, Forster TN, Stoffel K, Kuster MS. Early results in the treatment of proximal humeral fractures with a polyaxial locking plate. Arch Orthop Trauma Surg 2009;129:1367-74.
• Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am 2008;90:233-40.