Clinical Orthopaedics and Related Research®

, Volume 472, Issue 5, pp 1576–1585 | Cite as

Deltoid-split or Deltopectoral Approaches for the Treatment of Displaced Proximal Humeral Fractures?

  • Benjamin Buecking
  • Juliane Mohr
  • Benjamin Bockmann
  • Ralph Zettl
  • Steffen Ruchholtz
Clinical Research

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.

References

  1. 1.
    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.PubMedCrossRefGoogle Scholar
  2. 2.
    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.PubMedCrossRefGoogle Scholar
  3. 3.
    Constant CR. [Assessment of shoulder function] [in German]. Orthopade. 1991;20:289–294.PubMedGoogle Scholar
  4. 4.
    Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–164.PubMedGoogle Scholar
  5. 5.
    Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001;72:365–371.PubMedCrossRefGoogle Scholar
  6. 6.
  7. 7.
    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.PubMedCrossRefGoogle Scholar
  8. 8.
    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.PubMedCrossRefGoogle Scholar
  9. 9.
    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.PubMedCrossRefGoogle Scholar
  10. 10.
    Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2012;12:CD000434.Google Scholar
  11. 11.
    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.PubMedCrossRefGoogle Scholar
  12. 12.
    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.PubMedCrossRefGoogle Scholar
  13. 13.
    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.PubMedCrossRefGoogle Scholar
  14. 14.
    Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–186.PubMedCrossRefGoogle Scholar
  15. 15.
    Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–1089.PubMedGoogle Scholar
  16. 16.
    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.PubMedCrossRefGoogle Scholar
  17. 17.
    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.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    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.PubMedCrossRefGoogle Scholar
  19. 19.
    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.PubMedCrossRefGoogle Scholar
  20. 20.
    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.PubMedCrossRefGoogle Scholar
  21. 21.
    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.PubMedCrossRefGoogle Scholar
  22. 22.
    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.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Benjamin Buecking
    • 1
  • Juliane Mohr
    • 1
  • Benjamin Bockmann
    • 1
  • Ralph Zettl
    • 1
  • Steffen Ruchholtz
    • 1
  1. 1.Department of Trauma, Hand and Reconstructive SurgeryUniversity of Giessen and MarburgMarburgGermany

Personalised recommendations