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Complex proximal humerus fractures: Hertel’s criteria reliability to predict head necrosis

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Abstract

Background

The risk of post-traumatic humeral head avascular necrosis (AVN), regardless of the treatment, has a high reported incidence. In 2004, Hertel et al. stated that the most relevant predictors of ischemia after intracapsular fracture treated with osteosynthesis are the calcar length, medial hinge integrity and some specific fracture types. Based on Hertel’s model, the purpose of this study is to evaluate both its reliability and weaknesses in our series of 267 fractures, assessing how the anatomical configuration of fracture, the quality of reduction and its maintenance were predictive of osteonecrosis development, and so to suggest a treatment choice algorithm.

Materials and methods

A retrospective study, level of evidence IV, was conducted to duly assess the radiographic features of 267 fractures treated from 2004 to 2010 following Hertel’s criteria treated with open reduction and internal fixation by angular stability plates and screws. The average age was 65.2 years. The average follow-up was 28.3 ± 17.0 months. The percentage of AVN, the quality and maintenance of reduction obtained during surgery were evaluated.

Results

The AVN incidence was 3.7 %. No significant correlation with gender, age and fracture type was found. At the last follow-up X-ray, only 30 % presented all Hertel’s good predictors in the AVN group, 4.7 % in the non-AVN group (p < 0.05). About quality of reduction in the AVN group, it was poor in 50 %; while in the non-AVN group, it was poor in 3.4 % (p < 0.05). Four patients with AVN were symptomatic, and three needed a second surgery.

Conclusions

Hertel’s criteria are important in the surgical planning, but they are not sufficient: an accurate evaluation of the calcar area fracture in three planes is required. All fractures involving calcar area should be studied with CT.

Level of evidence

IV.

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Informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent for enrollment in the study and for the inclusion in this article of information that could potentially lead to their identification.

Human and animal rights

The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.

Conflict of interest

Campochiaro Gabriele, Rebuzzi Manuela, Baudi Paolo, Catani Fabio declare that they have no conflicts of interest.

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Authors and Affiliations

  1. University Department of Orthopaedics, Modena, Italy

    G. Campochiaro, P. Baudi & F. Catani

  2. Department of Orthopaedics and Traumatology, Piacenza Hospital, Piacenza, Italy

    M. Rebuzzi

Authors
  1. G. Campochiaro
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  2. M. Rebuzzi
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  3. P. Baudi
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  4. F. Catani
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Correspondence to M. Rebuzzi.

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Campochiaro, G., Rebuzzi, M., Baudi, P. et al. Complex proximal humerus fractures: Hertel’s criteria reliability to predict head necrosis. Musculoskelet Surg 99 (Suppl 1), 9–15 (2015). https://doi.org/10.1007/s12306-015-0358-z

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  • DOI: https://doi.org/10.1007/s12306-015-0358-z

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