Abstract
Background
Proximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3–35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel’s criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis.
Methods
In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN.
Results
HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer’s classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN.
Conclusion
We conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN.
Level of Evidence
Level 3, retrospective cohort study.
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References
Boesmueller, S., Wech, M., Gregori, M., et al. (2016). Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures. Injury, 47, 350–355. https://doi.org/10.1016/j.injury.2015.10.001
Lambert, S. M. (2018). Ischaemia, healing and outcomes in proximal humeral fractures. EFORT Open Reviews, 3, 304–315. https://doi.org/10.1302/2058-5241.3.180005
Hertel, R., Hempfing, A., Stiehler, M., & Leunig, M. (2004). Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. Journal of Shoulder and Elbow Surgery, 13, 427–433. https://doi.org/10.1016/j.jse.2004.01.034
Campochiaro, G., Rebuzzi, M., Baudi, P., & Catani, F. (2015). Complex proximal humerus fractures: Hertel’s criteria reliability to predict head necrosis. Musculoskeletal Surgery, 99(Suppl 1), S9-15. https://doi.org/10.1007/s12306-015-0358-z
Patel, S., Colaco, H. B., Elvey, M. E., & Lee, M. H. (2015). Post-traumatic osteonecrosis of the proximal humerus. Injury, 46, 1878–1884. https://doi.org/10.1016/j.injury.2015.06.026
Archer, L. A., & Furey, A. (2016). Rate of avascular necrosis and time to surgery in proximal humerus fractures. Musculoskeletal Surgery, 100, 213–216. https://doi.org/10.1007/s12306-016-0425-0
Moja, L., Piatti, A., Pecoraro, V., et al. (2012). Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One, 7, e46175. https://doi.org/10.1371/journal.pone.0046175
Ly, T. V., & Swiontkowski, M. F. (2008). Management of femoral neck fractures in young adults. Indian Journal of Orthopaedics, 42, 3–12. https://doi.org/10.4103/0019-5413.38574
Pauyo, T., Drager, J., Albers, A., & Harvey, E. J. (2014). Management of femoral neck fractures in the young patient: a critical analysis review. World Journal of Orthopaedics, 5, 204–217. https://doi.org/10.5312/wjo.v5.i3.204
Schnetzke, M., Bockmeyer, J., Loew, M., et al. (2018). Rate of avascular necrosis after fracture dislocations of the proximal humerus: timing of surgery. Obere Extremitat, 13, 273–278. https://doi.org/10.1007/s11678-018-0452-6
Spross, C., Platz, A., Rufibach, K., et al. (2012). The PHILOS plate for proximal humeral fractures–risk factors for complications at one year. Journal of Trauma and Acute Care Surgery, 72, 783–792. https://doi.org/10.1097/TA.0b013e31822c1b5b
Siebenbürger, G., Van Delden, D., Helfen, T., et al. (2015). Timing of surgery for open reduction and internal fixation of displaced proximal humeral fractures. Injury, 46(Suppl 4), S58-62. https://doi.org/10.1016/S0020-1383(15)30019-X
DePuy Synthes. 2016 PHILOS and PHILOS long: the anatomic fixation system for the proximal humerus. http://synthes.vo.llnwd.net/o16/LLNWMB8/INT%20Mobile/Synthes%20International/Product%20Support%20Material/legacy_Synthes_PDF/DSEM-TRM-0815-0449-1_LR.pdf.
Agudelo, J., Schürmann, M., Stahel, P., et al. (2007). Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. Journal of Orthopaedic Trauma, 21, 676–681. https://doi.org/10.1097/BOT.0b013e31815bb09d
Cruess, R. L. (1978). Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip. Clinical Orthopaedics and Related Research, 130, 86–93.
Gerber, C., Hersche, O., & Berberat, C. (1998). The clinical relevance of posttraumatic avascular necrosis of the humeral head. Journal of Shoulder and Elbow Surgery, 7, 586–590. https://doi.org/10.1016/s1058-2746(98)90005-2
Harrison, A. K., Gruson, K. I., Zmistowski, B., et al. (2012). Intermediate outcomes following percutaneous fixation of proximal humeral fractures. Journal of Bone and Joint Surgery. American Volume, 94, 1223–1228. https://doi.org/10.2106/JBJS.J.01371
Neer, C. S. (2006). Displaced proximal humeral fractures: part I. Classification and evaluation. 1970. Clinical Orthopaedics, 442, 77–82. https://doi.org/10.1097/01.blo.0000198718.91223.ca
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All authors contributed to the study conception and design. Material preparation and data collection were performed by TDS, D-BE, TMC and TM. Statistical analysis was performed by TDS. The first draft of the manuscript was written by TDS and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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Da Silva, T., Ehrhard, DB., Chuchuy, T.M. et al. Protective and Risk Factors for Humerus Head Necrosis After Proximal Humerus Fracture Treated with Internal Locking Plate. JOIO 56, 429–436 (2022). https://doi.org/10.1007/s43465-021-00500-8
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DOI: https://doi.org/10.1007/s43465-021-00500-8