Rate of avascular necrosis and time to surgery in proximal humerus fractures

Objectives: The aim of our study is to study the radiological and functionaloutcome of proximal humerus fractures treated via open reduction and internal fixation usingthe proximal humerus internal locking system or PHILOS. Study Design: Case series study.Period 05 years duration from January 2011 to December 2015. Setting: Large tertiary carecentre in Karachi, Pakistan. Materials and methods: The study population consisted of n=50patients all of whom underwent open reduction and internal fixation utilizing the proximalhumeral internal locking system or PHILOS for fractures of the proximal humerus. The inclusioncriterion was all the patients with closed fractures of the proximal humerus and were belongingto 2,3 and 4 part of the Neer system of classification. Physiotherapy was started as soon aspossible for the patients. Serial radiographic imaging in two views was done at 6, 12, 24 and52 weeks postoperatively. For the functional outcome of the procedure Constant and Murleyscoring system was used. Data was analyzed using IBM SPSS version 21. Results: The studypopulation consisted of n= 50 patients of which n= 35 were males and n= 15 were femaleshaving a mean age of 38.50 years. The mean duration of follow up was 24 months. All thepatients in the study had union of fracture both radiographically and clinically, the mean timeduration for the radiographically evident union of the humerus bone was 12 weeks with a rangeof 8 to 20 weeks, the mean Constant Murley score for the functional outcome of the shoulderjoint was 79 at the final follow up with a range of 50 to 100. Complications were found in n= 9patients and varus malunion was the most common complication. In our case series we did notobserve complications such as avascular necrosis, non union or implant failure. Conclusion:According to the results of our study the proximal humerus internal locking system or PHILOSis a good method for open reduction and internal fixation of the proximal humerus fractures andprovides a stable fixation, and has lower incidence of complications such as avascular necrosis.

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Which Classification of Proximal Humerus Fractures Leads to Postoperative Avascular Necrosis of the Humeral Head?

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2017.08.037 ◽

2017 ◽

Vol 33 (10) ◽

pp. e59

Author(s):

Takeshi Kawakami ◽

Teruhisa Mihata ◽

Akihiko Hasegawa

Keyword(s):

Avascular Necrosis ◽

Humeral Head ◽

Proximal Humerus ◽

Proximal Humerus Fractures ◽

Humerus Fractures

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Does cement augmentation of the screws in angular stable plating for proximal humerus fractures influence the radiological outcome: a retrospective assessment

Archives of Orthopaedic and Trauma Surgery ◽

10.1007/s00402-020-03362-1 ◽

2020 ◽

Vol 140 (10) ◽

pp. 1413-1421 ◽

Cited By ~ 4

Author(s):

Dominik Knierzinger ◽

Ulrich Crepaz-Eger ◽

Clemens Hengg ◽

Franz Kralinger

Keyword(s):

Avascular Necrosis ◽

Humeral Head ◽

Proximal Humerus ◽

Cement Leakage ◽

Cement Augmentation ◽

Proximal Humerus Fractures ◽

Radiological Outcome ◽

Anatomical Reduction ◽

Secondary Displacement ◽

Humerus Fractures

Abstract Background Screw-tip augmentation in angular stable plating offers new possibilities for the treatment of complex proximal humerus fractures. This retrospective analysis was performed to evaluate the radiological outcome of proximal humerus fractures treated with angular stable plates and additional screw-tip cement augmentation in patients over the age of 60. Materials and methods A retrospective single centre analysis was conducted from June 2013 to December 2016. The minimum follow-up time was set to 6 months after surgery. Anatomical reduction and fixation were evaluated in respect to reattached tuberosities to the head fragment and the adequate restoration of the calcar area not showing any valgus or varus malalignment. Complete fracture healing was determined 3 months after surgery. Any failures such as secondary displacement, primary screw perforation, intraarticular cement leakage and avascular necrosis of the humeral head with concomitant screw cut-out were assessed. Results In total, 24 patients (21 females; 3 males) at a median age of 77.5 (62–96) years were included. Five 2-part, twelve 3-part and seven 4-part fractures were detected. The measured median BMD value of 23 patients was 78.4 mg/cm3 (38.8–136.9 mg/cm3). Anatomical reduction was achieved in 50% of the patients. In most cases, the A level screws and the B1 screw were augmented with bone cement by a median of 7 (5–9) head screws used. Postoperative varus displacement was not detected in any of the patients. One patient (4.2%) sustained an early secondary displacement. Intraarticular cement leakage was detected in 3 patients (2 head-split fractures). Avascular necrosis of the humeral head was observed in 4 patients (16.7%). Revision surgery was necessary in four cases, using hemiarthroplasty twice and reverse shoulder arthroplasty the other two times. Conclusion Screw-tip augmentation in angular stable plating for proximal humerus fracture treatment showed a low secondary displacement rate of 4.2% in patients suffering from poor bone quality. Nevertheless, the occurrence of avascular necrosis of the humeral head with mainly severe fracture patterns observed in this study was higher compared to previously reported results in the literature. Cement augmentation in head-split fractures is not recommended, considering the high risk of an intraarticular cement leakage.

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Image Quiz: Proximal Humerus Fractures and Avascular Necrosis

JBJS Journal of Orthopaedics for Physician Assistants ◽

10.2106/jbjs.jopa.19.00013 ◽

2019 ◽

Vol 7 (4) ◽

pp. e0013

Keyword(s):

Avascular Necrosis ◽

Proximal Humerus ◽

Proximal Humerus Fractures ◽

Humerus Fractures

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Quantitative contrast enhanced dual energy CT to predict avascular necrosis: a feasibility study of proximal humerus fractures

BMC Medical Imaging ◽

10.1186/s12880-021-00717-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Kevin B. Hoover ◽

Alexandria O. Starks ◽

Valentina Robila ◽

Daniel L. Riddle

Keyword(s):

Avascular Necrosis ◽

Open Reduction ◽

Proximal Humerus ◽

Iodine Concentration ◽

Dual Energy ◽

Open Reduction Internal Fixation ◽

Dual Energy Ct ◽

Proximal Humerus Fractures ◽

Humerus Fractures

Abstract Background Avascular necrosis is a delayed complication of proximal humerus fractures that increases the likelihood of poor clinical outcomes. CT scans are routinely performed to guide proximal humerus fracture management. We hypothesized iodine concentration on post-contrast dual energy CT scans identifies subjects who develop avascular necrosis and ischemia due to compromised blood flow. Materials and methods 55 patients with proximal humerus fractures enrolled between 2014 and 2017 underwent clinical, radiographic and contrast enhanced dual energy CT assessment. Iodine densities of the humeral head and the glenoid (control) were measured on CT. Subjects managed with open reduction internal fixation or conservatively (non-surgical) were followed for up to two years for radiographic evidence of avascular necrosis. Arthroplasty subjects underwent histopathologic evaluation for ischemia of the resected humeral head. Results 17 of 55 subjects (30.9%) were treated conservatively, 21 (38.2%) underwent open reduction internal fixation and 17 of 55 (30.9%) underwent arthroplasty. Of the 38 subjects treated conservatively or with ORIF, 20 (52.6%) completed 12 months of follow up and 14 (36.8%) 24 months of follow up. At 12 months follow up, two of 20 subjects (10%) and at 24 months 3 of 14 subjects (21.4%) developed avascular necrosis. At 12 months, the mean humerus/glenoid iodine ratio was 1.05 (standard deviation 0.24) in subjects with AVN compared to 0.91 (0.24) in those who did not. At 24 months, subjects with avascular necrosis had a mean humerus/glenoid iodine concentration ratio of 1.06 (0.17) compared to 0.924 (0.21) in those who did not. Of 17 arthroplasty subjects, 2 had severe ischemia and an iodine ratio of 1.08 (0.30); 5 had focal ischemia and a ratio of 1.00 (0.36); and 8 no ischemia and a ratio of 0.83 (0.08). Conclusions Quantifying iodine using dual energy CT in subjects with proximal humerus fractures is technically feasible. Preliminary data suggest higher humeral head iodine concentration may increase risk of avascular necrosis; however, future studies must enroll and follow enough subjects managed with open reduction internal fixation or conservatively for two or more years to provide statistically significant results. Trial Registrations NCT02170545 registered June 23, 2014, ClinicalTrials.gov.

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