Abstract
Background
Proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated.
Questions/purposes
In this prospective randomized study, we aimed to investigate whether the deltoid-split approach is superior to the deltopectoral approach with regard to (1) complication rate; (2) shoulder function (Constant score); and (3) pain (visual analog scale [VAS]) for internal fixation of displaced humeral fractures with a polyaxial locking plate.
Methods
We randomized 120 patients with proximal humeral fractures to receive one of these two approaches (60 patients for each approach). We prospectively documented demographic and perioperative data (sex, age, fracture type, hospital stay, operation time, and fluoroscopy time) as well as complications. Followup examinations were conducted at 6 weeks, 6 months, and 12 months postoperatively, including radiological and clinical evaluations (Constant score, activities of daily living, and pain [VAS]). Baseline and perioperative data were comparable for both approaches. The sample size was chosen to provide 80% power, but it reached only 68% as a result of the loss of followups to detect a 10-point difference on the Constant score, which we considered the minimum clinically important difference.
Results
Complications or reoperations between the approaches were not different. Eight patients in the deltoid-split group (14%) needed surgical revisions compared with seven patients in the deltopectoral group (13%; p = 1.00). Deltoid-split and deltopectoral approaches showed similar Constant scores 12 months postoperatively (Deltoid-split 81; 95% confidence interval [CI], 74–87 versus deltopectoral 73; 95% CI, 64–81; p = 0.13), and there were no differences between the groups in terms of pain at 1 year (deltoid-split 1.8; 95% CI, 1.2–1.4 versus deltopectoral 2.5; 95% CI, 1.7–3.2; p = 0.14). No learning-curve effects were noted; fluoroscopy use during surgery and function and pain scores during followups were similar among the first 30 patients and the next 30 patients treated in each group.
Conclusions
The treatment of proximal humeral fractures with a polyaxial locking plate is reliable using both approaches. For a definitive recommendation for one of these approaches, further studies with appropriate sample size are necessary.
Level of Evidence
Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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References
Acklin YP, Stoffel K, Sommer C. A prospective analysis of the functional and radiological outcomes of minimally invasive plating in proximal humerus fractures. Injury. 2013;44:456–460.
Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand. 2004;75:741–745.
Constant CR. [Assessment of shoulder function] [in German]. Orthopade. 1991;20:289–294.
Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–164.
Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001;72:365–371.
DeStatis Statistisches Bundesamt. Hospital statistics. Wiesbaden 2011; Available at: http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/&p_aid=i&p_aid=36857213&nummer=702&p_sprache=D&p_indsp=522&p_aid=9442669;Download. Accessed June 14, 2012.
Duralde XA, Leddy LR. The results of ORIF of displaced unstable proximal humeral fractures using a locking plate. J Shoulder Elbow Surg. 2010;19:480–488.
Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005;430:176–181.
Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005;434:123–129.
Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2012;12:CD000434.
Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H. The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. J Shoulder Elbow Surg. 2008;17:21–28.
Kim SH, Szabo RM, Marder RA. Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008. Arthritis Care Res (Hoboken). 2012;64:407–414.
Königshausen M, Kübler L, Godry H, Citak M, Schildhauer TA, Seybold D. Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system? Injury. 2012;43:223–231.
Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–186.
Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–1089.
Röderer G, Abouelsoud M, Gebhard F, Böckers TM, Kinzl L. Minimally invasive application of the non-contact-bridging (NCB) plate to the proximal humerus: an anatomical study. J Orthop Trauma. 2007;21:621–627.
Röderer G, Erhardt J, Kuster M, Vegt P, Bahrs C, Kinzl L, Gebhard F. Second generation locked plating of proximal humerus fractures—a prospective multicentre observational study. Int Orthop. 2011;35:425–432.
Ruchholtz S, Hauk C, Lewan U, Franz D, Kühne C, Zettl R. Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study. J Trauma. 2011;71:1737–1744.
Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91:1320–1328.
Voigt C, Geisler A, Hepp P, Schulz AP, Lill H. Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma. 2011;25:596–602.
Warriner AH, Patkar NM, Curtis JR, Delzell E, Gary L, Kilgore M, Saag K. Which fractures are most attributable to osteoporosis? J Clin Epidemiol. 2011;64:46–53.
Wu CH, Ma CH, Yeh JJ, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71:1364–1370.
Acknowledgments
We thank Christian Kühne who did the surgery for some of the patients. In addition, we thank Daphne Asimenia Eschbach for valuable guidance in preparing the manuscript.
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Buecking, B., Mohr, J., Bockmann, B. et al. Deltoid-split or Deltopectoral Approaches for the Treatment of Displaced Proximal Humeral Fractures?. Clin Orthop Relat Res 472, 1576–1585 (2014). https://doi.org/10.1007/s11999-013-3415-7
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DOI: https://doi.org/10.1007/s11999-013-3415-7