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Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands

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European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Background

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries.

Methods

Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65–85). All completed a minimum 1-year follow-up (range 12.5–82 months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed.

Results

Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates.

Conclusion

Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

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Authors and Affiliations

  1. Department of Orthopaedics, Kaplan Medical Center, Derech Pasternak 1, 7661041, Rechovot, Israel

    Arie Greenberg, Philip J. Rosinsky, Nir Gafni, Yona Kosashvili & Alexander Kaban

  2. American Hip Institute, Des Plaines, IL, 60018, Israel

    Philip J. Rosinsky

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  1. Arie Greenberg
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  2. Philip J. Rosinsky
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Contributions

AG, NG, YK, and AK do not report any conflict of interest. PJR—Dr. Rosinsky—reports non-financial support from Arthrex, Stryker, Smith & Nephew, Ossur, outside the submitted work.

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Correspondence to Arie Greenberg.

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This study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. Details that might disclose the identity of the subjects under study have been omitted. This study was approved by the IRB (IRB ID: 0204-18-KMC).

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Greenberg, A., Rosinsky, P.J., Gafni, N. et al. Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands. Eur J Orthop Surg Traumatol 31, 769–777 (2021). https://doi.org/10.1007/s00590-020-02832-x

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