Could direct transdeltoid approach to severely displaced proximal humerus fracture be advantageous for a better reduction?

Tommaso Maluta; Andrea Amarossi; Manuel De Masi; Andrea Dorigotti; Matteo Ricci; Eugenio Vecchini; Stefano Negri; Elena Manuela Samaila; Bruno Magnan

doi:10.23750/abm.v92iS3.12583

Could direct transdeltoid approach to severely displaced proximal humerus fracture be advantageous for a better reduction?

Authors

Tommaso Maluta
Andrea Amarossi Orthopaedics and Surgery Department. University of Verona https://orcid.org/0000-0001-9987-5541
Manuel De Masi
Andrea Dorigotti
Matteo Ricci
Eugenio Vecchini
Stefano Negri
Elena Manuela Samaila
Bruno Magnan

DOI: https://doi.org/10.23750/abm.v92iS3.12583

Keywords:

Humeral Fractures, Locking plate, Deltopectoral approach, Transdeltoid approach, Greater tuberosity fractures

Abstract

Background: Surgical treatment of proximal humeral fractures (PHF) is a challenge for orthopaedic surgeons. Despite the wide application of open reduction and internal fixation with locking plates, the optimal surgical approach of PHF is still debated. This study aims to evaluate the radiological outcomes, defined as anatomical restoration of the greater tuberosity and humeral head-shaft angle, of the deltopectoral (DPA) and the lateral transdeltoid (LTA) approaches in three- and four-part PHF, treated with locking plate.

Materials and methods: This retrospective series review identifies 74 PHF surgically treated between January 2012 and December 2019. Patients were divided into two groups according to the surgical approach (DPA vs LTA). Demographic data, duration of surgery, radiological pre- and post-surgery parameters (greater tuberosity displacement and humeral head-shaft angle) were collected. The association between the surgical approach and the quality of fractures reduction was assessed.

Results: The use of LTA approach correlates with a better reduction of greater tuberosity displacements compare to DPA (63% in DPA vs 100% LTA). No significant association was found with the humeral head-shaft angle (restored in 89% of the patients in DPA and 86% in LTA group), and surgical times (range 40 – 210 minutes ± DS 33,56 for the DPA; range 45 – 170 minutes ± 29,60 for LTA).

Conclusions: The results of this radiological study suggest that PHF with significant displacement of the grater tuberosity could benefit from the adoption of a lateral transdeltoid approach for the ORIF procedure. Further studies are needed to confirm these findings.

References

Bartonícek J, Dzupa V, Fric V, Pacovský V, Skála-Rosenbaum J, Svatos F. [Epidemiology and economic implications of fractures of proximal femur, proximal humerus, distal radius and fracture-dislocation of ankle]. Rozhl Chir 2008;87:213–9.

S N. Complex Proximal Humeral Fractures (Three or Four Part) with Dislocation: Outcome Analysis of Percutaneous Reduction and External Fixation. MOJ Orthop Rheumatol 2016;6:17–23. https://doi.org/10.15406/mojor.2016.06.00237.

Knowelden J, Buhr AJ, Dunbar O. Incidence of fractures in persons over 35 years of age. A report to the MRC working party on fractures in the elderly. Br J Prev Soc Med 1964;18:130–41.

Donaldson LJ, Cook A, Thomson RG. Incidence of fractures in a geographically defined population. J Epidemiol Community Health 1990;44:241–5. https://doi.org/10.1136/jech.44.3.241.

Maluta T, Amarossi A, Dorigotti A, Bagnis F, Samaila EM, De Luca L, et al. External fixation can be an option for proximal humerus fractures Neer 3-4. Acta Biomed 2020;91:e2020017. https://doi.org/10.23750/abm.v91i14-S.10979.

Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87–92. https://doi.org/10.1097/01.blo.0000194672.79634.78.

Fjalestad T, Hole MØ. Displaced proximal humeral fractures: operative versus non-operative treatment--a 2-year extension of a randomized controlled trial. Eur J Orthop Surg Traumatol 2014;24:1067–73. https://doi.org/10.1007/s00590-013-1403-y.

Baudi P, Campochiaro G, Serafini F, Gazzotti G, Matino G, Rovesta C, et al. Hemiarthroplasty versus reverse shoulder arthroplasty: Comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture. Musculoskelet Surg 2014;98. https://doi.org/10.1007/s12306-014-0322-3.

Verdano MA, Lunini E, Pellegrini A, Corsini T, Marenghi P, Ceccarelli F. Can the osteosynthesis with locking plates be a better treatment for unstable fractures of the proximal humerus? Musculoskelet Surg 2014;98:27–33. https://doi.org/10.1007/s12306-013-0267-y.

Vicenti G, Antonella A, Filipponi M, Conserva V, Solarino G, Carrozzo M, et al. A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: Results after 5 years. Injury 2019;50:S80–8. https://doi.org/10.1016/j.injury.2019.01.051.

Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090–103.

Robinson CM, Murray IR. The extended deltoid-splitting approach to the proximal humerus: variations and extensions. J Bone Joint Surg Br 2011;93:387–92. https://doi.org/10.1302/0301-620X.93B3.25818.

Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754–65. https://doi.org/10.5435/00124635-200612000-00007.

Robertson DD, Yuan J, Bigliani LU, Flatow EL, Yamaguchi K. Three-dimensional analysis of the proximal part of the humerus: relevance to arthroplasty. J Bone Joint Surg Am 2000;82:1594–602. https://doi.org/10.2106/00004623-200011000-00013.

DeLude JA, Bicknell RT, MacKenzie GA, Ferreira LM, Dunning CE, King GJW, et al. An anthropometric study of the bilateral anatomy of the humerus. J Shoulder Elb Surg 2007;16:477–83. https://doi.org/10.1016/j.jse.2006.09.016.

Hertel R, Knothe U, Ballmer FT. Geometry of the proximal humerus and implications for prosthetic design. J Shoulder Elb Surg 2002;11:331–8. https://doi.org/10.1067/mse.2002.124429.

Pearl ML. Proximal humeral anatomy in shoulder arthroplasty: Implications for prosthetic design and surgical technique. J Shoulder Elb Surg 2005;14:99S-104S. https://doi.org/10.1016/j.jse.2004.09.025.

Rouleau DM, Mutch J, Laflamme G-Y. Surgical Treatment of Displaced Greater Tuberosity Fractures of the Humerus. J Am Acad Orthop Surg 2016;24:46–56. https://doi.org/10.5435/JAAOS-D-14-00289.

Klug A, Wincheringer D, Harth J, Schmidt-Horlohé K, Hoffmann R, Gramlich Y. Complications after surgical treatment of proximal humerus fractures in the elderly—an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating. J Shoulder Elb Surg 2019;28:1674–84. https://doi.org/10.1016/j.jse.2019.02.017.

Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int 2005;16:65–72. https://doi.org/10.1007/s00198-004-1714-2.

Blonna D, Castoldi F, Scelsi M, Rossi R, Falcone G, Assom M. The hybrid technique: potential reduction in complications related to pins mobilization in the treatment of proximal humeral fractures. J Shoulder Elb Surg 2010;19:1218–29. https://doi.org/10.1016/j.jse.2010.01.025.

Williams GRJ, Wong KL. Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning. Orthop Clin North Am 2000;31:1–21. https://doi.org/10.1016/s0030-5898(05)70124-3.

Fattoretto D, Borgo A, Iacobellis C. The treatment of complex proximal humeral fractures: analysis of the results of 55 cases treated with PHILOS plate. Musculoskelet Surg 2016;100:109–14. https://doi.org/10.1007/s12306-015-0395-7.

Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, et al. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elb Surg 2018;27:1526–34. https://doi.org/10.1016/j.jse.2018.03.009.

Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: Current concepts in classification, treatment and outcomes. J Bone Jt Surg - Ser B 2011;93 B:1–11. https://doi.org/10.1302/0301-620X.93B1.25702.

Burkhart KJ, Dietz SO, Bastian L, Thelen U, Hoffmann R, Müller LP. Behandlung der proximalen Humerusfraktur des Erwachsenen. Dtsch Arztebl Int 2013;110:591–7. https://doi.org/10.3238/arztebl.2013.0591.

Xie L, Zhang Y, Chen C, Zheng W, Chen H, Cai L. Deltoid-split approach versus deltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2019;105:307–16. https://doi.org/10.1016/j.otsr.2018.12.004.

Knežević J, Mihalj M, Čukelj F, Ivanišević A. MIPO of proximal humerus fractures through an anterolateral acromial approach. Is the axillary nerve at risk? Injury 2017;48 Suppl 5:S15–20. https://doi.org/10.1016/S0020-1383(17)30733-7.

Traver JL, Guzman MA, Cannada LK, Kaar SG. Is the Axillary Nerve at Risk During a Deltoid-Splitting Approach for Proximal Humerus Fractures? J Orthop Trauma 2016;30:240–4. https://doi.org/10.1097/BOT.0000000000000492.

Bockmann B, Buecking B, Franz D, Zettl R, Ruchholtz S, Mohr J. Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: A prospective observational study. BMC Musculoskelet Disord 2015;16:1–7. https://doi.org/10.1186/s12891-015-0618-y.

George MS. Fractures of the greater tuberosity of the humerus. J Am Acad Orthop Surg 2007;15:607–13. https://doi.org/10.5435/00124635-200710000-00005.

Unnithan A, Matti Z, Hong TF. Outcome following Fractures of the Greater Tuberosity of the Humerus: A Retrospective Study. Shoulder Elb 2013;5:221–5. https://doi.org/10.1111/sae.12023.

White EA, Skalski MR, Patel DB, Gross JS, Tomasian A, Heckmann N, et al. Isolated greater tuberosity fractures of the proximal humerus: anatomy, injury patterns, multimodality imaging, and approach to management. Emerg Radiol 2018;25:235–46. https://doi.org/10.1007/s10140-018-1589-8.

Mattyasovszky SG, Burkhart KJ, Ahlers C, Proschek D, Dietz SO, Becker I, et al. Isolated fractures of the greater tuberosity of the proximal humerus: A long-term retrospective study of 30 patients. Acta Orthop 2011;82:714–20. https://doi.org/10.3109/17453674.2011.618912.

Assunção JH, Malavolta EA, Beraldo RA, Gracitelli MEC, Bordalo-Rodrigues M, Ferreira Neto AA. Impact of shoulder rotation on neck-shaft angle: A clinical study. Orthop Traumatol Surg Res 2017;103:865–8. https://doi.org/10.1016/j.otsr.2017.04.007.

Jia X-Y, Chen Y-X, Qiang M-F, Zhang K, Li H-B, Jiang Y-C, et al. Postoperative Evaluation of Reduction Loss in Proximal Humeral Fractures: A Comparison of Plain Radiographs and Computed Tomography. Orthop Surg 2017;9:167–73. https://doi.org/10.1111/os.12332.

Petros RSB, Ribeiro FR, Teno AC, Filho RB, Filardi Junior CS, Dal Molin DC. Proximal humerus fracture with locking plate: Functional and radiographic results. Acta Ortop Bras 2019;27:164–8. https://doi.org/10.1590/1413-785220192703142049.

Large TM, Adams MR, Loeffler BJ, Gardner MJ. Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures. J Am Acad Orthop Surg 2019;27:794–805. https://doi.org/10.5435/JAAOS-D-18-00225.