Minimally invasive plate osteosynthesis of the humeral shaft with regard to adjacent anatomical characteristics

The study goal was to evaluate the distances from the radial (RN), the musculocutaneous (MN) and axillary nerves (AN) and the medial neurovascular bundle of the upper arm to a minimally invasive applied plate and to define its relation to the RN during different degrees of malrotation during MIPO. The sample involved ten upper extremities. Application of a PHILOS plate was performed through a Delta-split. Intervals between the AN, MN, RN and the medial vascular bundle were defined at various positions. The humeral shaft was artificially fractured at a height of about the mean of the plate. The distal fragment was brought into 15° and 30° internal (IR) as well as external rotation (ER) and here, the plate’s relation to the RN was evaluated. The medial neurovascular bundle intersected the plate at its distal part in two specimens. Regarding the distances from the RN to the plate during different rotation positions the distances became significantly longer during ER, respectively shorter during IR. The medial neurovascular bundle and the RN were identified as the main structures at risk. Care must be taken during distal screw placement and malrotation exceeding 15° must be avoided during MIPO.

Clinico-radiological and functional outcome of surgical management of displaced two part, three part and four part proximal humeral fractures in adults treated by PHILOS plate in a tertiary care hospital in North India: a prospective study of 30 patients

Background: Treatment of proximal humeral fractures is challenging. In the past, the fractures were treated conservatively which compromised the functional results. PHILOS plate provides a good functional outcome with context to the early joint mobilization and rigid fixation of the fracture.Methods: This was the prospective study of 30 patients aged 20 to 60 years (mean age 48.4 years) with proximal humeral fractures including two part, three part and four part fractures based on Neer’s classification, treated by open reduction internal fixation with PHILOS plating. Functional outcome was assessed using Constant-Murley Score.Results: The final outcome was observed at 6 months follow up. The results were comparable with the existing literature. The Mean Constant Score at 6 month follow up was 79.4, range (38 to 92). Out of 30, (n = 12, 40%) had excellent outcome, (n = 9, 30%) had good functional outcome, 6 (20%) had moderate outcome, 3 (10 %) had poor outcome. Out of 30 patients, one patient with four part fracture had a lowest CS of 38. Complications were observed in 5, (16.7%) patients. Varus malunion in one patient, avascular necrosis in one patient, stiffness in one patient.Conclusions: PHILOS plate gives stable fixation, enables early range of motion and minimizes complications with good functional outcome if done with expert hands.

A STUDY ON FUNCTIONAL OUTCOME OF PROXIMAL HUMERUS FRACTURES TREATED WITH PHILOS PLATING

Background: Proximal humerus fractures are common and debilitating injuries. These fractures have a dual age distribution occurring either in young people following high energy trauma Usually high energy trauma associated with dislocation or in those older than 60 years with low-velocity injuries like simple fall, especially in elderly patients is due to osteoporosis and deforming forces of muscle attached. Wide range of treatment modalities ranging from conservative management to reverse shoulder arthroplasty. The non-operative method gives good results in stable and minimally displaced fractures. Displaced humeral neck fractures used to be managed conservatively in the past, but these were complicated by loss of reduction, malunion, non-union, stiffness and ultimately poor functional outcome. We took up this study to assess the efcacy and functional outcome of P.H.I.L.O.S. plating in proximal humerus. Our objectives are to study the fracture pattern with the Neer's criteria, to reconstruct the proximal humerus fracture anatomically with Philos plate, allow early shoulder mobilization and assessing the functional outcome using Constant Murley score. It is an Materials and methods: observational study of 30 patients (18 females and 12 males) with proximal humerus fractures that attended to the Department of Orthopaedics, Government General Hospital, Rangaraya medical college, Kakinada from December 2018 to December 2020. The mean follow-up Results: period was 12 months. Two patients lost follow-up. Of the remaining 28 patients, all fractures were united clinically and radiologically. At the nal follow-up the mean Constant-Murley score was 69.2 (range 50 -100). The results were excellent in 3, good in 12, fair in 10 patients, poor in 3 patients. During the follow-up 4 cases had varus mal-union, 5 had stiffness of the shoulder, 2 had supercial infection and1 had screw penetration. No cases of hardware failure, locking screw loosening or non-union were noted. T Conclusion: he divergent and convergent orientation of the locking screws of PHILOS plate provides stable biological xation with good radiological union. It minimises the soft tissue dissection and gives both axial and angular stability hence, reducing the risk of fracture displacement.

Treatment of humeral fractures with long PHILOS plates using a modified technique and approach avoids radial nerve palsy in the last 10 years

Objective Radialis paresis is a known complication of plate osteosynthesis of the proximal humeral shaft. There are major differences with regard to surgical approach and implant. The standard treatment is a lateral-lateral approach. Here, iatrogenic damage to the radial nerve is a relevant complication. In our institution, these fractures have been treated with an adapted procedure for about 10 years. A long Philos plate is inserted proximally via a deltoido-pectoral approach. The plate is first torqued distally by about 45°-90° and then lies anteriorly on the humerus. The distal screws can be placed via anterior stab incisions. The advantage of this technique is that the implant and approach respect the anatomical course of the radial nerve and it does not have to be manipulated in an open exploratory manner. The aim of the study is to demonstrate the effectiveness of the surgical technique in relation to iatrogenic radial nerve paresis in comparison to the literature. Methods We analysed patients with a proximal humeral shaft fracture who were treated at our clinic with a long torqued philos plate using the adapted surgical method over the last 10 years. The fracture, the occurrence of iatrogenic radial damage and biometric data of the patients were analysed retrospectively. Results We found a total of 59 patients who underwent surgery according to the above-mentioned scheme between 2010 and 2020. The average age was 70.1 (40-101) years. There were 44 women and 15 men. 2 patients had a preoperatively documented radial nerve damage. In 57 patients, no damage could be found in the radialis supply area both pre- and postoperatively. 2 patients died shortly after surgery, 6 patients were loss to follow up. 2 patients had a tear of the distal plate bearing (1 malcompliance/1 pseudarthrosis). Both had to be revised. In the remaining 47 patients (78%), the healing process was unremarkable. Conclusion The described treatment of the proximal humeral shaft fracture has been successfully practised at our clinic for 10 years. Most of the fractures healed without complications. Compared to the exploration of the nerve, this method respects the anatomical course of the nerve and shows in the retrospective analysis that no iatrogenic damage to the radial nerve occurred. Thus, the surgical method represents a valid alternative to the established implants and classical surgical treatments.

Application of a lateral intertubercular sulcus plate in the treatment of proximal humeral fractures: A finite element analysis and example in clinical practice

Background: Inversion deformities caused by insufficient medial support are especially common when the PHILOS locking plate is used to treat proximal humeral fractures. Using finite element analysis, the present study aimed to compare the biomechanical properties of a PHILOS locking plate (PLP) and a PLP combined with a lateral intertubercular sulcus plate (PLP-LSP) in the fixation of proximal humeral fractures with loss of the medial column. We also present the results of a 69-year-old female patient with a comminuted fracture of the proximal right humerus (Neer type four-part fracture) who underwent successful surgical treatment with a PHILOS plate combined with an auxiliary lateral intertubercular sulcus plate. Methods: After creating a three-dimensional finite element model of a proximal humeral fracture with loss of the medial column, three implant models were established. A full-screw PLP was used in Group A, a PHILOS plate lacking medial screw support and an auxiliary plate (MPLP-LSP) was used in Group B, and a full-screw PLP-LSP was used in Group C. The three fixation models were applied to the proximal humeral fracture model, following which horizontal, compressive, and rotational loads were applied to the humerus model. We evaluated structural stiffness and stress distribution of the implant and compared displacement and angle changes among the three models. Results: Displacement and angle changes were smallest in Group C (PLP-LSP) compared to those in Group A and Group B. The implant model used in Group C also showed the highest structural rigidity, endured less von Misses stress, and had the strongest stability than that used in Group A and Group B. Conclusion: An LSP placed at the internodal grove not only aids in anatomical reduction but also provides effective lateral and medial support, thereby reducing stress on the PLP and providing better stability in patients with proximal humeral fractures.

Application of a Lateral Intertubercular Sulcus Plate in the Treatment of Proximal Humeral Fractures: a Finite Element Analysis and Example in Clinical Practice

Background: Inversion deformities caused by insufficient medial support are especially common when the PHILOS locking plate is used to treat proximal humeral fractures. Using finite element analysis, the present study aimed to compare the biomechanical properties of a PHILOS locking plate (PLP) and a PHILOS plate combined with a lateral intertubercular sulcus plate (PLP-LSP) in the fixation of proximal humeral fractures with loss of the medial column. We also present representative results for a 69-year-old female patient with a comminuted fracture of the proximal right humerus (Neer type four-part fracture) who underwent successful surgical treatment with a PHILOS plate combined with an auxiliary lateral intertubercular sulcus plate. Methods: After creating a three-dimensional finite element model of proximal humeral fracture with loss of the medial column, three implant models were established. A full-screw PHILOS plate (PLP) was used in Group A, while a PHILOS plate lacking medial screw support and an auxiliary plate were used in Group B (MPLP-LSP). A full-screw PHILOS plate and auxiliary plate were used in Group C (PLP-LSP). The three fixation models were applied to the proximal humerus fracture model, following which horizontal, compressive, and rotational loads were applied to the humerus model. We evaluated the structural stiffness and stress distribution of the implant and compared displacement and angle changes among the three models. Results: Displacement and angle changes were smallest in Group C (PLP-LSP). The implant model used in Group C also had the highest structural rigidity, endured less von Misses stress than the other two models , and had the strongest stability. In our clinical case, X-ray and computed tomography images obtained 3 months after the operation indicated that the fracture had healed, with good positioning of internal fixation and good functional recovery.Conclusion: A lateral intertubercular sulcus plate placed at the internodal grove not only aids in anatomical reduction but also provides effective lateral and medial support, thereby reducing stress on the PHILOS plate and providing better stability in patients with proximal humeral fractures.

EVALUATION OF RESULTS OF PROXIMAL HUMERUS FRACTURE TREATED BY PHILOS PLATTING

Purpose: To assess the functional outcome of proximal humerus fracture treated with Proximal Humerus Internal Locking osteosynthesis (PHILOS) plating. Methods: Functional outcomes of 30 patients aged 30 to 75 (mean 57) years who underwent Philos plate xation for proximal humeral fractures were evaluated after taking informed consent about the study. Indications for surgery were 2-part, 3-part or 4-part closed proximal humeral fractures with angulation of more than 45 degrees or displacement of more than 1 cm. All patients satisfying the inclusion criteria were operated and followed up for 6 months .Functional outcomes and shoulder range of movement were assessed based on the Constant scoring system and was done at 6 months postoperatively. Result: Patients were followed up for 6 months. All fractures healed satisfactorily. No wound infections, vascular injuries, avascular necrosis, or loss of xation ensued. One patients with axillary nerve palsy recovered spontaneously within 3 months. Functional outcome was excellent in 11 patients, good in 15, and moderate in 4. The mean Constant score was 83(range 40–100). Conclusion: Proximal humerus fractures treated by Open Reduction and Internal Fixation by Philos plate have good functional results with low complication rates.