detailed journal club presentation on factors that influence reduction loss in proximal humerus fracture surgery

1. SRI SIDDHARTHA MEDICAL COLLEGE,TUMKUR
DEPARTMENT OF ORTHOPAEDICS
Topic:
Factors that influence reduction loss in proximal humerus
fracture surgery
MODERATOR:
DR. JK REDDY
PROFESSOR & HOD
DEPT. OF ORTHOPAEDICS
PRESENTER:
DR. JAIPALSINH MAHIDA
JR. RESIDENT (M.S ORTHO)
DEPT. OF ORTHOPAEDICS

2. INTRODUCTION
Proximal humerus comprises 4 main osseous segments
1. Humeral head
2. Lesser tuberosity
3. Greater tuberosity
4. Humeral shaft
Proximal humerus fractures account upto
• 45% of all humeral fractures
• 4-5% of all fractures in body
Blood supply to proximal humerus depends on
• Anterior circumflex humeral artery
• Posterior circumflex humeral artery

3. Fracture occurs more commonly in elderly
high energy trauma (fall on outstreached hand) is cause In young patients
Displacement of fracture segments due to muscle pull
• Greater tuberosity – superiorly & posteriorly by supraspinatus
• Lesser tuberosity – medially by subscapularis
• Humerus shaft – adducted medially by pectoralis major
• Proximal fracture fragment – abducted by deltoid
Primary goal for surgical treatment for displaced proximal humerus
fractures
• Restore shoulder function improve active motion, strength & function
• Bone union with good alignment with various treatments

4. Proximal humerus locking plate osteosynthesis - gold standard surgical
treatment
• deltopectoral approach which is minimally invasive & preserves circumflex artery
Restoration of medial support – proven to be important factor for good
functional outcome
 Previous biomechanical study showed
• angular LCP
• Most rigid under 3 load tests
 Varus bending, medial shearing & axial torque
• Could resist physiological loads encountered in osteoporosis
Despite these improvements, complications have been described
• Implant related problems (screw perforation, loosening, plate impingement, metal failure)
• Reduction loss
• Humeral head osteonecrosis
• Non union
• infection

5. Most common cause of re-operation
• Implant related problems
• Reduction loss
• 4.2-13.7%
• Results from old age, osteoporosis, severe comminution, technical error, patient non-
compliance
• complications results in poor functional outcome
This study hypothesized
All variables (age, gender, hypertension, diabetes mellitus, mechanism of
injury, bone mineral density, neer& ota fracture type, neck-shaft angle,
medial comminution, surgical approach or medial support) influenced
reduction loss & identified risk factors of reduction loss after lCP fixation of
proximal humerus.

6. classification
In 1886, Kocher T. was the first one to devise a classification of
proximal humeral fractures. His classification was based on
anatomical levels of fractures :
Anatomical neck
Epiphyseal region
Surgical neck.
Kocher classification

7. In 1955 Watson-Jones classified fractures of upper end of humerus
into Abduction and Adduction types, depending on the mechanism
of injury
In 1934, Codman EA classified upper end humerus fractures into
four distinct fragments, occurring roughly along the anatomical lines
of epiphyseal union
• He was able to differentiate four major
fragments: the anatomical head,
the greater tuberosity, the lesser tuberosity,
and the shaft. Codman's conclusion was
that all fractures were some combination
of these different fracture fragments
Codman classification

8. . In 1970 Neer CS, based his four-part classification of upper end
humerus on Codmans classification. This was the first truly
comprehensive system that considered the anatomical and
biomechanical forces resulting in the amount of displacement of
fracture fragments and related these factors to diagnosis and
treatment. It is the most commonly used classification for proximal
humeral fractures
• When any of the four major segments is displaced greater than 1 cm, or
angulated more than 45°, the fracture is considered displaced. Fissure lines
or hairline fractures are not considered displaced fragments. A fragment
may have several undisplaced components: these should not be considered
separate fragments since they are in continuity and are held together by soft
tissue.

9. • Neer has also emphasized the term fracture-dislocation
 Fracture dislocations can be classified according to direction (anterior or posterior) as well as to
the number of fracture fragments (two-part, three-part or four-part).
• Head-splitting fractures and impression fractures of the articular surface are special fracture

10. Neer’s Classification

11. AO CLASSIFICATION
• 11A – extra-articular, unifocal fracture
11A-1 :- greater tuberosity
11a-2 :- surgical neck metaphysis impacted
11a-3 :- surgical neck metaphysis not impacted
• 11b – extra-articular, bifocal fracture
11b-1 :- three part surgical neck, metaphysis impacted
11b-2 :- three part surgical neck, metaphysis not impacted
11b-3 :- extra-articular fracture with glenohumeral dislocation
• 11c – articular fracture
11c-1 :- slight displacement
11c-2 :- marked displacement
11c-3 :- with glenohumeral dislocation or head-split

13. Patients and methods
Included 285 patients treated with locking plate between January
2004 – December 2011.
All operation performed by a single surgeon.
Standardised x-ray (true AP and axillary lateral view) were used to
evaluate neer ao ota fracture type, initial nsa (varus displacement),
medial comminution, post operative nsa (reduction adequacy),
medial support restoration, healing progress, reduction loss, implant
related problem immediately after surgery and at 2 weeks, 1month, 3
months , 6 months, 9 months and atleast 1year after surgery.

14. Surgical indication based on neer classification
• SHOULDER JOINT FRACTURE WITH DISLOCATION >10mm DISPLACEMENT OF
FRACTURE FRAGMENT, 5MM DISPLACEMNT OF GT, ANGULAR
DISPLACEMENT >450 ANGLE, OR LOSS OF MEDIAL METAPHYSEAL COLUMN.
EXCLUSION CRITERIA
• NON-DISPLACED / MINIMALLY DISPLACED WITH STABILITY.
• OPEN FRACTURE AND PATHOLOGICAL FRACTURE
7 PATIENTS DIED, 15 PATIENTS LOST TO FOLLOW UP AND 3 PATIENTS
REFUSED TO PARTICIPATE
FINALLY 252 PATIENTS(49 MAN, 203 WOMAN) INCLUDED IN THE
STUDY
AVERAGE AGE 62.1( 25-92 YEARS )

15. PATIENTS DIVIDED INTO 2 GROUPS
REDUCTION LOSS REDUCTION MAINTENANCE
1. INCLUDED 17 PATIENTS (AVERAGE
AGE 68.2±12 YEARS)
2. >100 ANGULATION IN ANY DIRECTION
3. >5MM HEIGHT LOSSOF HUMERAL
HEAD FROM PLATE
4. FIXATION FAILURE
1. INCLUDED 235 PATIENTS (AVERAGE
AGE 61±12.4 YEARS)
2. 100 ANGULATION IN ANY DIRECTION
3. <5MM HEIGHT LOSSOF HUMERAL
HEAD FROM PLATE
4. NO FIXATION FAILURE

16. MECHANISM OF INJURY DIVIDED INTO
NSA WAS THE ANGLE BETWEEN LINE PERPENDICULAR TO LINE
FROM SUPERIOR TO INFERIOR BORDER OF ARTICULAR SURFACE AND
A LINE BISECTING HUMERAL SHAFT
• NORMAL NSA 1300 (RANGE, 120-140 DEGREES)
• POST OPERATIVE NSA 120-1400 INDICATED ADEQUATE REDUCTION
• NSA <1100 – DISPLACED VARUS FRACTURE
HIGH ENERGY TRAUMA LOW ENERGY TRAUMA
FALLING FROM HEIGHT HIGHER THAN
STANDING HEIGHT, MOTOR VEHICLE
ACCIDENT, DIRECT BLOW.
RESULT OF FALLING FROM STANDING
HEIGHT OR LESS

17. MEDIAL COMMINUTION WAS DEFINED AS ATLEAST 1 BONY
FRAGMENT IN MEDIAL SURGICAL AREA OR LOSS OF MEDIAL
METAPHYSEAL COLUMN.
• 3D CT WAS USED TO CONFIRM MEDIAL COMMINUTION AND ARTICULAR
INVOLVEMENT.
FUNCTIONAL OUTCOME WERE EVALUATED WITH VISUAL ANALOG
SCALE FOR PAIN AND CONSTANT SORE AT FINAL FOLLOW-UP

18. SURGICAL TECHNIQUE
UNDER GA PATIENT IN SUPINE POSITION
IN DELTOPECTORAL APPROACH
• 10-15CM SKIN INCISION FROM CORACOID PROCESS TO DELTOID INSERTION
• DISSECTION BETWEEN DELTOID AND PECTORALOS MAJOR TO INCISED
FASCIA AND EXPOSE FRACTURE SITE
• CARE TAKEN TO AVOID INJURY TO AXILLARY NERVE AND CIRCUMFLEX
ARTERY
• AFTER OPEN REDUCTION, 3-5 HOLE LCP FIXED
IN MINIMALLY INVASIVE (DELTOID SPLITTING) APPROACH
• 4-5 CM SKIN INCISION FROM ACROMION EXTENDING DISTALLY
• AFTER INDIRECT REDUCTION 3-5 HOLE PLATE FIXATION PERFORMED

19. PHILOS PLATE WAS USED IN ALL CASES
FROM MAY 2009 MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS WAS
PREFERRED PROCEDURE EXCEPT IN CASE OF AO TYPE C3
SHOULDER WAS IMMOBILISED FOR 1-2 WKS POST OP.
GENTLE PASSIVE MOTION OF SHOULDER STARTED AS SOON AS
PATIENT WAS COMFORTABLE.
ACTIVE MOTION OF ELBOW, WRIST AND HAND BEGUN ON 1ST POST
OPERATIVE DAY.
ACTIVE SHOULDER MOVEMENT STARTED AT 4-6 WKS
STRENGHTENING EXERCISE STARTED AT 12 WKS

20. RESULTS
COMPLICATIONS
• 20 IMPLANT RELATED PROBLEMS (SCREW-PERFORATION, PLATE
IMPINGEMENT, CUT-OUT, CUT-THROUGH, PLATE FAILURE) – 7.9%
• 17 REDUCTION LOSS - 6.7%
• 5 AVASCULAR NECROSIS - 2%
• 5 NON-UNION - 2%
• 3 AXILLARY INJURY - 1.2%
• 3 INFECTIONS -1.2%

21. VISUAL ANALOG SCALE SCORE IN REDUCTION LOSS GROUP WAS
NOT SIGNIFICANTLY DIFFERENT FROM REDUCTION MAINTENANCE,
BUT CONSTANT SCORE IN REDUCTION LOSS WAS SIGNIFICANTLY
DIFFERENT FROM REDUCTION MAINTENANCE
OUT OF 17 REDUCTION LOSS, 13 UNDERWENT CONVERSION
SURGERY TO ARTHROPLASTY AND 4 UNDERWENT REVISION
SURGERY FOR PLATE REFIXATION AND AUTOGENOUS BONE GRAFT
FROM PELVIC ILIUM
IN 15 CASES, ACUTE REDUCTION LOSS OCCURRED WITHIN 1 MONTH
AFTER SURGERY
 IN 2 CASES, LATE REDUCTION LOSS WITH SCREW PERFORATION OR
LOOSENING OCCURRED AT 3-6 MONTHS

22. REDUCTION LOSS AND REDUCTION MAINTENANCE DID NOT DIFFER
IN TERMS OF GENDER, HYOERTENSION , DIABETES, MECHANISM OF
INJURY, NEER OR OTA FRACTURE TYPE, DELTOPECTORAL APPROACH
REDUCTION LOSS REDUCTION MAINTENANCE
1. AGE OLDER (68.2±12YEARS) YOUNGER (61.02±12.4YEARS)
2.BMD LOWER (-2.8±0.7) HIGHER (-1.8±0.6)
3.INITIAL NSA LOWER (96.6±16.50) HIGHER (115.5±13.30)
4.RATE OF MEDIAL
COMMINUTION
MORE COMMON (17 OF 17) LESS COMMON (118 OF 235)
5.POST OPERATIVE NSA LOWER (123.6±15.60) HIGHER (130.6±8.30)
6.INSUFFICIENT MEDIAL
SUPPORT
MORE COMMON (15 OF 17) LESS COMMON (27 OF 235)

23. UNIVARIABLE REGRESSION ANALYSIS REVEALED THAT AGE,
OSTEOPOROSIS, VARUS DISPLACEMENT, MEDIAL COMMINUTION,
REDUCTION ADEQUACY AND INSUFFICIENT MEDIAL SUPPORT HAD
SIGNIFICANT CORRELATION WITH REDUCTION LOSS
MULTIVARIABLE LOGISTIC ANALYSIS REVEALED THAT
OSTEOPOROSIS, VARUS DISPLACEMENT, MEDIAL COMMINUTION ,
INSUFFICIENT MEDIAL SUPPORT WERE INDEPENDENT RISK FACTORS
FOR REDUCTION LOSS

24. DISCUSSION
THANASAS ET AL. REVIEWED 12 STUDIES WITH 791 PATIENTS
• REPORTED RE-OPERATION RATE WAS- 13.7%
• MOST COMMON CAUSE FOR RE-OPERATION
• REDUCTION LOSS- 31%
• AVN- 21%
• IMPLANT FAILURE- 20%
SPROWL ET AL. REVIEWED 12 STUDIES WITH 514 PATIENTS
• COMPLICATION RATE WAS - 49%
• RE-OPERATION RATE – 14%
• MOST COMMON COMPLICATION
• VARUS MAL UNION - 16%
• AVN- 10%
• SCREW PERFORATION - 8%

25. KRAPPINGER ET AL. REPORTED THAT BONE QUALITY, BIOLOGICAL AGE,
ANATOMICAL REDUCTION AND MEDIAL CORTICAL SUPPORT INFLUENCE
SUCCESSFUL SURGICAL TREATMENT AND RECOMMENDED PRIMARY
ARTHROPLASTY SHOULD BE CONSIDERED IF ANATOMIC REDUCTION AND
RESTORATION OF MEDIAL CORTICAL SUPPORT CANNOT BE ACHIEVED
FOR MOST FRACTURE REDUCTION LOSS IS MORE COMMON AMONG
OLDER PATIENT
POST OPERATIVE NSA CAN ALSO INFLUENCE RISK OF REDUCTION LOSS
• AGLUDELO ET AL. REPORTED 30.4% INCIDENCE OF LOSS OF FIXATION IN CASES
WITH VARUS MAL REDUCTION AND 11% INCIDENCE IN CASES WITH POST-
OPERATIVE HEAD SHAFT ANGLE >1200
• IN CURRENT STUDY, REDUCTION LOSS OCCURRED IN 6 CASES WITH POST
OPERATIVE VARUS POSITION (6 OF 17) AND IN 11 CASES WITH POST OPERATIVE
ADEQUATE POSITION (11 OF 235)

26. REDUCTION LOSS DID NOT OCCUR MORE FREQUENTLY WITH
DELTOPECTORAL APPROACH (11 OF 147) THAN WITH MINIMALLY
INVASIVE APPROACH (6 OF 104)
• DESPITE MANY FAVOURABLE CLINICAL OUTCOME MINIMALLY INVASIVE APPROACH
WAS NOT SUPERIOR AND SHOULD NOT BE EXAGGERATED IN TERMS OF
REDUCTION LOSS
OSTEOPOROSIS WIDELY ACCEPTED RISK FACTOR FOR REDUCTION LOSS
• MANAGEMENT OF OSTEOPOROSIS MAY REDUCE INCIDENT OF FRAGILITY
FRACTURE AND COMPLICATION OF FRACTURE TRETAMENT
• REDUCTION LOSS MAY BE BECAUSE OF POOR BONE QUALITY
• HYMES ET AL. REPORTED CANCELLOUS BONE DENSITY AND TOTAL CANCELLOUS
SCREW DEPTH PENETRATION WERE CRITICAL VARIABLES
• MATASSI ET AL. REPORTED USE OF LOCKING PLATE WITH FIBULAR GRAFT
AUGMENTATION IS A SAFE AND RELIABLE TECHNIQUE TO SUPPORT HUMERAL
HEAD

27. • ANGULAR STABLE OPEN REDUCTION AND INTERNAL FIXATION ARE
ASSOCIATED WITH HIGH COMPLICATION AND REVISION RATES AMONG
OSTEOPOROTIC PATIENTS SO PRIMARY HEMI ARTHROPLASTY IS SUITABLE
OPTION
• THE BMD DATA CAN INFLUENCE DECISION TO PERFORM OSTEOSYNTHESIS
VERSUS ARTHROPLASTY FOR PROXIMAL HUMERUS FRACTURE
IN CURRENT STUDY, DISPLACEMENT OF HUMERAL HEAD INTO
VARUS ALIGNMENT WAS ASSOCIATED WITH A HIGHER FAILURE RATE
THAN VALGUS OR NEUTRAL WHICH SUGGEST FRACTURE WITH
VARUS ALIGNMENT ARE MORE LIKELY TO DISRUPT MEDIAL
BUTTRESS AND BE UNSTABLE
MEDIAL COMMINUTION IS INDEPENDENT RISK FACTOR FOR
REDUCTION LOSS
• OSTERHOFF ET AL. REPORTED THAT CALCAR COMMINUTION WAS RELEVANT
AND EASY TO DETECT PROGNOSTIC FACTOR

28. COMBINED CASES OF INITIAL VARUS DISPLACEMENT AND MEDIAL
SIDE COMMINUTION HAVE HIGH RISK OF REDUCTION LOSS FOR
PROXIMAL HUMERUS FRACTURE, SO INFERIOMEDIAL SCREW
FIXATION AND RESTORATION OF MEDIAL SUPPORT BY CORTEX TO
CORTEX REDUCTION ARE MOST IMPORTANT FACTOR FOR
PREVENTING REDUCTION LOSS
FROM SURGICAL POINT OF VIEW MEDIAL SUPPORT IS PROBABLY
MOST IMPORTANT PROCEDURE FOR PREVENTION OF REDUCTION
LOSS IN UNSTABLE PROXIMAL HUMERUS FRACTURE
LIMITATION OF THIS STUDY
• INVOLVES SMALL NUMBER OF CASES OF REDUCTION LOSS
• MOST OF MEASUREMENTS SHOWED GOOD RELIABILITY BUT SOME ONLY
SHOWED FAIR RELIABILITY
• SOME 4 PART FRACTURE OF NEER TYPE AND SOME B FRACTURE OF OTA
WERE INTERPRETED AS 3 PART AND TYPE C
• WAS A RETROSPECTIVE STUDY

29. CONCLUSION
REDUCTION LOSS ATER SURGICAL TREATMENT FOR PROXIMAL
HUMERUS FRACTURE OCCURRED AT RATE OF 6.7%
MULTIVARIABLE REGRESSION ANALYSIS REVEALED OSTEOPOROSIS,
DISPLACED VARUS FRACTURE, MEDIAL COMMINUTION,
INSUFFICIENT MEDIAL SUPPORT WERE INDEPENDENT RISK FACTOR
FOR REDUCTION LOSS AFTER SURGERY FOR PROXIMAL HUMERUS.

30. THANK YOU