Evaluation of screw placement in proximal humerus fractures regarding drilling manoeuvre and surgeon's experience☆
Introduction
Proximal humerus fractures represent circa 5% of all fractures, with notable increase of incidence in elderly women [1]. Regarding young patients, they are mostly the result of high-energy traumas, whereas in the older population these fractures occur commonly due to osteoporotic bone constitutions.
The treatment of proximal humerus fractures has been a very moving subject and is still a controversial topic in orthopaedic and trauma surgery. Currently, the literature lacks scientific evidence for the best treatment option. Although most of these fractures are stable and can be treated conservatively [2], a large variety of techniques has been described for their surgical treatment [2], [3], [4], [5], [6]. Surgical intervention is recommended for displaced fractures and commonly involves open reduction and internal fixation (ORIF). Unfortunately, clinically relevant complications following this procedure have been described by several authors [7], [8], [9], [10]. In order to reduce these complication rates, an anatomically pre-shaped proximal humeral internal locking system (PHILOS, Synthes GmbH, Oberndorf, Switzerland) was developed to improve screw fixation in the osteoporotic bone and to minimize soft tissue damage. Stable screw fixation is especially necessary in the osteoporotic bone since osteoporotic fractures tend to be more complex with progress of the disease as postulated by Court-Brown et al. [11]. The PHILOS plate provides angular stability which is especially useful in osteoporotic bone [12] and recently published clinical studies show promising outcomes regarding their use [13,14]. Nevertheless, complication rates ranging up to 40%, including post-interventional dislocations as well as loss of reduction and screw perforations have been reported [15].
The aim of this study was to determine the efficacy of proximal humerus plating regarding screw length, over penetration of humeral head, surgeon's experience and different drill techniques in a cadaveric model.
Section snippets
Sample composition
A total of 45 upper extremities from adult human cadavers donated to science, embalmed with Thiel´s method [16,17], were evaluated. All investigated cadavers were donated to the Department of Macroscopic and Clinical Anatomy of the Medical University of Graz under the approval of the Anatomical Donation Program of the University of Graz and according to the Austrian law for donations. The collective consisted of 22 limbs from female and 23 upper extremities from male donors. Their age ranged
Results
In total, 46 PHILOS and 44 Hofer plates were tested. Hereof, 45 were performed by use of a sharp (381 plate holes) and 45 with a worn drill bit (385 plate holes). Further, 45 were tested by the experienced surgeons and 45 by the novice group. Regarding the joint perforation rate, 14 holes (3.6%; total collective: 385 holes) were primary penetrated in the subgroup who used the worn drill bits and in 19 holes (5%; total collective: 381 holes) the simulated joint was perforated in the group that
Discussion
Diverse traumas following drilling beyond the far cortex including vascular lacerations [18], tendon ruptures [19] and pseudoaneurysms [20,21] have been described in the literature for both the upper and lower extremities. During proximal humerus plating, the anterior and posterior circumflex humeral arteries as well as the axillary nerve (AN) represent potential structures at risk. Regarding the latter, palsies of the nerve after ORIF have been described [22] and during a cadaver study,
Informed consent
Body donors gave their written informed consent during their lifetime.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interest
All authors declare that they have no conflict of interest.
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2022, European Journal of Orthopaedic Surgery and Traumatology
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This paper is part of a supplement supported by The Croatian Trauma Society.