The mean vas pain score was.4 (range, 07). The mean operation time was 117.3 min (range, 77208). At final follow-up, 7 patients rated their outcome as excellent, 5 as good, 10 as satisfied and 8 as dissatisfied. Complications (Table 3 ) occurred in 30 of patients (9 patients). In 5 patients, (17 ) secondary screw cut-out due to varus collapse was seen; of those, 5 patients were treated with reosteosynthesis at 6, 8, 10, 11 and 12 weeks after initial surgery. Table 3 Complications and outcome after treatment using the philos plate 1 male 75 4 part 2 Screw cut out dissatisfied 2 female 70 4 part 2 Screw cut out satisfied 3 male 62 4 part 3 Screw cut out dissatisfied 4 female.
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The clinical evaluation was performed by one independent examiner (OR) who was not part of the surgical team. Radiological evaluation included an X-ray of the affected shoulder in at least 2 standard projections anteroposterior (AP) and axial and/or y views. The x-ray evaluation was focused on malreduction, malunion, nonunion, avn, loss of reduction and screw or pin perforation. Statistical analysis Data consistency was checked and data were screened for outliers and normality by using quantile plots. Paired Students t-tests were used to compare variables between groups. All reported tests were two-sided, and p -values .05 were considered to be statistically significant. All statistical analyses in this report were performed with statistica 10 (Hill,. Statistics: Methods and Applications. Results Group 1 philos plate After a mean follow-up.4 months (range, 2656 months patients scored.9 points (range, 1587) on the cms. The mean ucla score was.1 points (range, 1535 and the mean sst was.1 points (range, 112 respectively. The mean abduction was 109.7 (range, 40170 and mean anterior flexion was 128.3 (range, 40170).small
Active abduction and anterior elevation were allowed after sling removal, while load-bearing and heavy manual work was allowed after 1012 weeks. Data collection/clinical and radiological evaluation The constant-Murley score (CMS) 17, the ucla score 18 and the simple Shoulder Test (SST) 19 were determined. The constant-Murley score includes the pain score, functional assessment, range of motion and strength measurement with a maximum score of 100 points. The ucla score includes pain, function, satisfaction and strength with a maximum score of 35 points. The simple Shoulder Test comprises 12 yes-or no-response questions to objective and subjective items. The visual analog pain scale (VAS) 20 was used to rate the patients general subjective pain. Range of motion was measured using a goniometer. The patients were also asked to rate their subjective satisfaction at the final follow-up as either excellent, good, satisfied or dissatisfied.
Tuberosities are percutaneously fixed using.7 mm.0 mm paper cannulated screws. Finally, the two.5 mm k-wires are tightened and a few millimeters are cut off of the humerusblock. 5 An elevator is introduced into the fracture gap via a small skin incision to reduce the head by lifting it a, b Postoperative rehabilitation Patients in group 1 were treated with immobilization of the shoulder in a sling for 2 weeks. Active finger, wrist and elbow movement was allowed on the first postoperative day, and pendulum exercises of the shoulder were started at least 14 days postoperatively. Active abduction up to 90 was started after the sling was removed, depending on surgeon-specified guidelines. Heavy manual work and resistive exercises were allowed 8 to 12 weeks postoperatively. The postoperative rehabilitation protocol of patients in group 2 included wearing a shoulder sling for 4 weeks. Finger writings and elbow movements were allowed immediately postoperatively.
Special screw driver for Humerusblock to fix the headless pins. B shows Humerusblock insertion guide together with Kirschner-wire centering sleeve and two.5 mm Kirschner wires. C shows Humerusblock insertion guide, kirschner-wire centering sleeve and Kirschner wires from lateral. D Kirschner wires crossing over at an angle of 25 through the humerusblock The humerusblock is inserted via a 3 cm skin incision at the lateral aspect of the upper arm, approximately 5 cm distal to the subcapital fracture level. The humerusblock is fixed to the shaft with a self-tapping cannulated.5 mm screw. Two.5 mm k-wires are introduced into the shaft up to the fracture level in the so-called waiting position. Then, the closed reduction under manual traction and fluoroscopy control is performed. The surgeon holds the arm and reduces the fracture, and the assistant drills the k-wires to the subchondral level. The reduction of the tuberosities and/or the lifting or derotating of the head is performed via small skin incision using hooks and elevators, as seen in Fig.
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The philos plate was temporarily secured at the humeral shaft with k-wires, and a non-locking screw was introduced through the plate in the shaft. Holes for the head screw were made by subchondral drilling under fluoroscopy control in order to avoid perforating the joint. Before the end of surgery, the final result was assessed by fluoroscopy. The summary humerusblock is made of stainless steel and is made for the fixation of 2 k-wires up.5 mm in diameter (Fig. The 2 lateral canals for the k-wires are at an angle of 35 at the lower plane of the implant and at a 25 angle to each other, which makes the k-wires cross over and diverge in the humeral head. The k-wires are locked in the humerusblock by small pins.
The humerusblock itself is secured at the shaft by.5 mm self-tapping screw at the shaft. 4 The humerusblock implant and instruments. A shows kirschner-wire centering sleeve with two.5 mm Kirschner wires. Insertion guide and drill sleeve for Humerusblock. humerusblock with two offset canals for the kirschner wires and two headless pins for locking the kirschner wires in the humerusblock. 3.5 mm self-tapping cortex screw to fix the humerusblock to the lateral aspect of the humeral bone.
X-rays in 2 planes postoperatively. Matching criteria and outcome are illustrated in Table 2 Fig. 3 a valgus, impacted 3-part fracture of a left shoulder treated using the humerusblock a,. X-ray postsurgical after Humerusblock. X-rays in 2 planes at final follow-up after 40 months.
Matching criteria and outcome are illustrated in Table 2 Table 2 An example of two matched patients gender female female age 62 64 handedness left left affected arm left left fracture type valgus impacted 3-part Valgus impacted 3-part accident bike home fall asa. General anesthesia in combination with an interscalene block were used in all procedures, and all patients received perioperative intravenous antibiotic prophylaxis. In group 1, (philos) a deltopectoral approach was used in all of the patients. First, the tuberosities were tagged with non-absorbable number 2 or 3 sutures behind the rotator cuff insertion. Then, the humeral head was reduced and fixed with k-wires. The philos plate was then adapted, and the tuberosities were reduced by tying them together over the plate.
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Therefore, 30 patients treated using the philos plate were matched to 30 Humerusblock patients according to the matching criteria. In both groups, there were 20, 4-part fractures and 10, 3-part fractures. Group 1 (philos) comprised 30 patients (17 female, 13 men) with a mean age.3 years (range, 3680 years). Group 2 (HB) also comprised 30 (17 female, 13 men) patients with a mean age.7 years (range, 3778 years). Table 1 shows details of the matched pairs. Figures 2 and 3 show an example of a matched-pair analysis, and Table 2 shows the demographics and outcomes of the example. Table 1 Patient demographics Age (range).3 (3680).7 (3778).5 (3680) Gender Male female handedness right left 7 7 14 Side (injured arm) right left or time min (range) 117.3 (77208).1 (31206).7 (31208) Accident Low energy (home fall, pedestrian) Traffic (bike, motorcycle. 2 a valgus, impacted 3-part fracture of a left shoulder treated using the philos plate.
Demographic data were used to retrospectively review a prospectively gathered database of the 291 patients treated with either the philos plate or the humerusblock to perform a matched-pair analysis. Patients were matched for age (within /3 years gender, handedness (dominant or non-dominant affected workbook side and fracture type (3-or 4-part proximal humeral fracture by neers classification system). The matching procedure was blinded to the outcome. The minimum follow-up was 24 months after surgery. Exclusion criteria were head-split fractures, lesions of the brachial plexus, pathologic fractures, dementia, previous surgery on the affected shoulder, heavy tobacco abuse, alcohol abuse or steroid intake. 1, limitation of the humerusblock. The long metaphyseal fracture line reaching far below makes it impossible to stabilize the fracture with the humerusblock 86 Patients (43/group) fulfilled the matching criteria and were contacted to return for clinical and radiological evaluation. Of those, 15 died and 11 did not return for evaluation.
proximal humeral fractures using either the philos plate (Synthes, Oberdorf, Switzerland) or the humerusblock (Synthes, Oberdorf, Switzerland). 139 patients were treated with philos plate, and 152 were treated with the humerusblock. In our institutions, the philos plate and the humerusblock are used. Usage of either implant depends on the preference of the surgeon. The humerusblock can be used for subcapital and intra-articular humeral fractures (AO/ota classification A3, B1-3, C1-3). Due to its design, the only limitation of the humerusblock is the use in ao a2 metaphyseal fractures with fractures level extending far below the surgical neck (Fig. Use of either the philos plate or the humerusblock was decided by the surgeons with the patient and was not randomized or blinded.
The vas pain score was significantly lower in group 2 than in group 1 (1.2.4; p.01). The mean abduction (109.7 vs 133.7; p.01) and anterior flexion (128.3 vs 145.7; p.01) were significantly worse in group. The mean operation time was significantly shorter in group 2 (117.3.1, p.01). Complications occurred in 30 (group 1) and 23 (group 2) of patients. In this study, the functional outcome is superior in the humerusblock group. However, the general outcome after surgical treatment of 3-and 4-part fractures is moderate, and the complication rate has to be considered, even though it can be lowered with the use of minimally invasive implants. Keywords, proximal humeral fracturesLocking platePercutaneous pin fixationHumerusblock. Patients and methods, the study was reviewed and approved by the hospital institutional the review board (Ethikkommission für das Bundesland Salzburg).
James McLean Upper Limb & shoulder Surgery Adelaide
Received:, accepted:, abstract, background, the ideal method for the surgical treatment of proximal humeral fractures has not yet been found. We therefore conducted a retrospective matched-pair analysis and daddy compared osteosynthesis with open reduction and internal fixation and that with an angular stable plate with minimally invasive, closed reduction, percutaneous fixation with the humerusblock. Methods, during a study period of 3 years, we matched 30 patients treated with angular stable plates (group 1) for age, gender, fracture type and handedness (dominant or nondominant) to 30 patients treated using the humerusblock (group 2). At a minimal follow-up of 24 months, clinical evaluation included the constant-Murley score, the ucla score and the simple Shoulder Test. Subjective pain was evaluated using the vas pain scale. Patients were asked to rate their subjective satisfaction of final outcome as excellent, good, satisfied or dissatisfied. Results, the mean cms, ucla score and sst differed significantly between groups 1 and 2 (60.9.9, p.01 (25.1.5, p.01) and (8.1.4, p.05 respectively.