Operative Treatment of Proximal Humeral Fracturedislocations Through an Anterolateral Deltoid Split Approach

Document Type : RESEARCH PAPER

Authors

Department of Trauma Surgery, Kantonsspital Graubünden, Loëstrasse, Chur, Switzerland

Abstract

Background: Proximal humeral fracture-dislocations (PHFD) are a special entity in proximal humeral fracture
treatment. The aim of this study is to present our minimally invasive plate osteosynthesis (MIPO) technique through
an anterolateral deltoid split approach. In addition, we performed a retrospective cohort study analyzing the patient
reported functional outcome and complications.
Methods: A single center cohort study was performed. All patients operated through a deltoid split approach for PHFD
between 2009 and 2016 were eligible for inclusion. The primary endpoint was subjective shoulder function measured with
QuickDASH and subjective shoulder value (SSV). Secondary endpoints were complications and implant-related irritation.
Results: 28 patients were included. The mean age was 49 (SD ± 10.3). The mean follow-up was 48 months (SD ±
23.7). The mean QuickDASH score was 6.8 (SD ±7.8) and the mean SSV was 86 (SD ±14.6). Four patients had a
conversion into a reversed arthroplasty (14%), one patient (4%) a shortening of secondary perforated screws, four
patients an early re-osteosynthesis (14%), four patients (14%) developed an AVN and in one patient damage of the
axillary nerve was observed. 21 patients (75%) had their implant removed.
Conclusion: Patient reported functional results after humeral head preservation and internal fixation of PHFDs through
an anterolateral deltoid spilt approach are promising. However, there is a high rate of re-operations either because of
complications or for implant removal. Comparing our data to literature these rates are not depending on the approach chosen.
Level of evidence: IV

Keywords


1. Court-Brown CM, Garg A, McQueen MM. The
epidemiology of proximal humeral fractures. Acta
orthopaedica Scandinavica. 2001; 72(4):365-71.
2. Trikha V, Singh V, Choudhury B, Das S. Retrospective
analysis of proximal humeral fracture-dislocations
managed with locked plates. Journal of Shoulder and
Elbow Surgery. 2017; 26(10):e293-9.
3. Beks RB, Ochen Y, Frima H, Smeeing DP, van der
Meijden O, Timmers TK, et al. Operative versus
nonoperative treatment of proximal humeral
fractures: a systematic review, meta-analysis, and
comparison of observational studies and randomized
controlled trials. Journal of Shoulder and Elbow
Surgery. 2018; 27(8):1526-34.
4. 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.
5. Soliman OA, Koptan WM. Four-part fracture
dislocations of the proximal humerus in young adults:
results of fixation. Injury. 2013; 44(4):442-7.
6. Hawkins RJ, Switlyk P. Acute prosthetic replacement
for severe fractures of the proximal humerus.
Clinical Orthopaedics and Related Research®. 1993;
289:156-60.
7. Kokkalis ZT, Iliopoulos ID, Antoniou G, Antoniadou T,
Mavrogenis AF, Panagiotopoulos E. Posterior shoulder
fracture–dislocation: an update with treatment
algorithm. European Journal of Orthopaedic Surgery
& Traumatology. 2017; 27(3):285-94.
8. Frombach AA, Brett K, Lapner P. Suppl-6, M3:
Humeral Head Replacement and Reverse Shoulder
Arthroplasty for the Treatment of Proximal Humerus
Fracturesm. The Open Orthopaedics Journal. 2017;
11:1108.
9. Acklin YP, Sommer C. Plate fixation of proximal
humerus fractures using the minimally invasive
anterolateral delta split approach. Operative
Orthopädie und Traumatologie. 2012; 24(1):61-73.
10. Frima H, Michelitsch C, Beks RB, Houwert RM, Acklin
YP, Sommer C. Long-term follow-up after MIPO Philos
plating for proximal humerus fractures. Archives of
orthopaedic and trauma surgery. 2019; 139(2):203-9.
11. 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.
12. Ruedi TP, Buckley RE, Moran CG. AO principles of
fracture management. 2nd expanded ed. / [edited by]
Thomas P. Rüedi, Richard E. Buckley, Christopher G.
Moran. ed. Davos Platz, [Switzerland]: AO Pub.; 2007.
13. Angst F, Schwyzer HK, Aeschlimann A, Simmen
BR, Goldhahn J. Measures of adult shoulder
function: Disabilities of the arm, shoulder, and
hand questionnaire (DASH) and its short version
(QuickDASH), shoulder pain and disability index
(SPADI), American Shoulder and Elbow Surgeons
(ASES) Society standardized shoulder assessment
form, constant (Murley) score (CS), simple shoulder
test (SST), Oxford shoulder score (OSS), shoulder
disability questionnaire (SDQ), and Western ontario
shoulder instability index (WOSI). Arthritis care &
research. 2011; 63:S174.
14. Jost B, Pfirrmann CW, Gerber C. Clinical outcome after
structural failure of rotator cuff repairs. JBJS. 2000;
82(3):304-14.
15. Hulsmans MH, van Heijl M, Houwert RM, Hammacher
ER, Meylaerts SA, Verhofstad MH, et al. High irritation
and removal rates after plate or nail fixation in
patients with displaced midshaft clavicle fractures.
Clinical Orthopaedics and Related Research®. 2017;
475(2):532-9.
16. 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. Journal of orthopaedic trauma. 2009;
23(3):163-72.
17. Acklin YP, Stoffel K, Sommer C. A prospective
analysis of the functional and radiological outcomes
of minimally invasive plating in proximal humerus
fractures. Injury. 2013; 44(4):456-60.
18. Beaton DE, Wright JG, Katz JN, Upper Extremity
Collaborative Group. Development of the QuickDASH:
comparison of three item-reduction approaches. JBJS.
2005; 87(5):1038-46.
19. Audigé L, Goldhahn S, Daigl M, Goldhahn J, Blauth M,
Hanson B. How to document and report orthopedic
complications in clinical studies? A proposal for
standardization. Archives of orthopaedic and trauma
surgery. 2014; 134(2):269-75.
20. Greiner S, Kääb MJ, Haas NP, Bail HJ. Humeral
head necrosis rate at mid-term follow-up after
open reduction and angular stable plate fixation
for proximal humeral fractures. Injury. 2009;
40(2):186-91.
21. Falez F, Papalia M, Greco A, Teti A, Favetti F, Panegrossi
G, et al. Minimally invasive plate osteosynthesis
in proximal humeral fractures: one-year results
of a prospective multicenter study. International
orthopaedics. 2016; 40(3):579-85.
22. Robinson CM, Khan LA, Akhtar MA. Treatment
of anterior fracture-dislocations of the proximal
humerus by open reduction and internal fixation. The
Journal of Bone and Joint Surgery. British Volume.
2006; 88(4):502-8.
23. Schliemann B, Theisen C, Kösters C, Raschke MJ,
Weimann A. Reverse total shoulder arthroplasty
for type I fracture sequelae after internal fixation of
proximal humerus fractures. Archives of Orthopaedic
and Trauma Surgery. 2017; 137(12):1677-83.
24. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors
of humeral head ischemia after intracapsular fracture
of the proximal humerus. Journal of shoulder and
elbow surgery. 2004; 13(4):427-33.
25. Bastian JD, Hertel R. Initial post-fracture humeral
head ischemia does not predict development of
necrosis. Journal of shoulder and elbow surgery.
2008; 17(1):2-8.