Corrective Osteosynthesis in Failed Proximal Humeral Fractures

Abstract

Despite implant improvement and increasing standardisation of operation techniques, the rate of therapy failure of proximal humeral fracture care with primary osteosyntheses is estimated to be 10 to 20%. Most commonly failure is precipitated by: material failure, technical error, non-anatomical repositioning, avascular necrosis, lacking medial support. An additive medial stabilisation of the so-called “calcar region” can decrease failure rates significantly. An early correction osteosynthesis with the purpose of restoring the anatomy is indicated in bony, non-consolidated “fresh” fractures. Bony consolidated fractures should be classified according to Boileau and Walch. The authors of this article advice a structured and classification-adapted approach to treatment with a correction osteosynthesis. Post-traumatic deficits can be augmented utilising the following methods: correction osteosynthesis with allogeneic/autologous bone grafts, correction osteosynthesis with hydroxyapatite grafts. For the additive stabilisation of repositioned and fixated fractures, the following are described: correction osteosynthesis with an additive ventral one-third tubular plate, correction osteosynthesis with cement-augmented screws. Based on results of endoprosthetics following fractures of the proximal humerus, the correction osteosynthesis indeed represents a real therapeutic alternative in patients that are below the age of 60, a good bone mass and with relative functional requirements.

Key words

fracture sequelae - Boileau classification - correction - osteotomy

Publication History

Article published online:
21 October 2019

• References/Literatur

• 1 Passaretti D, Candela V, Sessa P. et al. Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area. J Shoulder Elbow Surg 2017; 26: 2117-2124 doi:10.1016/j.jse.2017.05.029
• 2 Lill H, Voigt C, Jensen G. et al. Korrekturosteosynthesen proximaler Humerusfrakturen. Unfallchirurg 2015; 118: 18-28 doi:10.1007/s00113-014-2682-4
• 3 Duparc F. Malunion of the proximal humerus. Orthop Traumatol Surg Res 2013; 99 (1 Suppl.): S1-S11 doi:10.1016/j.otsr.2012.11.006
• 4 Habermeyer P, Schweiberer L. [Corrective interventions subsequent to humeral head fractures]. Orthopäde 1992; 21: 148-157
• 5 Katthagen JC, Huber M, Grabowski S. et al. Failure and revision rates of proximal humeral fracture treatment with the use of a standardized treatment algorithm at a level-1 trauma center. J Orthop Traumatol 2017; 18: 265-274
• 6 Osterhoff G, Baumgartner D, Favre P. et al. Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. J Shoulder Elbow Surg 2011; 20: 740-746
• 7 Zhang L, Zheng J, Wang W. et al. The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study. Int Orthop 2011; 35: 1655-1661
• 8 Voigt C, Kreienborg S, Megatli O. et al. How does a varus deformity of the humeral head affect elevation forces and shoulder function? A biomechanical study with human shoulder specimens. J Orthop Trauma 2011; 25: 399-405
• 9 Boileau P, Trojani C, Chuinard C. et al. Proximal humerus fracture sequelae: Impact of a new radiographic classification on arthroplasty. Clin Orthop Relat Res 2006; 442: 121-130
• 10 Boileau P, Trojani C, Walch G. et al. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 2001; 10: 299-308
• 11 Raiss P, Edwards TB, Collin P. et al. Reverse shoulder arthroplasty for malunions of the proximal part of the humerus (type-4 fracture sequelae). J Bone Joint Surg Am 2016; 98: 893-899
• 12 Kristensen MR, Rasmussen JV, Elmengaard B. et al. High risk for revision after shoulder arthroplasty for failed osteosynthesis of proximal humeral fractures: a matched pair analysis of 285 cases from the Danish Shoulder Arthroplasty Registry. Acta Orthop 2018; 89: 345-350
• 13 Sebastia-Forcada E, Lizaur-Utrilla A, Cebrian-Gomez R. et al. Outcomes of reverse total shoulder arthroplasty for proximal humeral fractures: primary arthroplasty versus secondary arthroplasty after failed proximal humeral locking plate fixation. J Orthop Trauma 2017; 31: e236-e240
• 14 Meller R, Krettek C. Folgezustände nach proximaler Humerusfraktur. Unfallchirurg 2015; 118: 576
• 15 Walch G, Badet R, Nové-Josserand L. et al. Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting. J Shoulder Elbow Surg 1996; 5: 161-168
• 16 Vlachopoulos L, Schweizer A, Meyer DC. et al. Three-dimensional corrective osteotomies of complex malunited humeral fractures using patient-specific guides. J Shoulder Elbow Surg 2016; 25: 2040-2047 doi:10.1016/j.jse.2016.04.038