Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Ralph B. Blasier, MD, JD*,
Sinai-Grace Hospital, Detroit, Michigan
Posted February 2008
When I read this article, I felt a sense of relief; but more on that later.
There is an old aphorism, almost certainly true, that when
there are many methods to treat a surgical problem, no one method is
particularly good. This was the situation in the treatment of displaced
proximal humeral fractures before the advent of the locked-screw proximal
humeral plating systems. Until that time, accepted methods to treat displaced
proximal humeral fractures included the following:
- Nonoperative treatment and acceptance of any subsequent substantial malunion
- Excision of the head fragment and prosthetic hemiarthroplasty
- Fixation with plate and screws (L-plate, T-plate, blade-plate, or bent fibular plate)
- Mostly intramedullary fixation (Rush rods, Ender nails, or multiplanar locking nails)
- Pin, wire, suture combinations (Steinmann pins and wire, Steinmann pins and suture, or wire or suture alone)
Before the advent of the locked-screw proximal humeral
plating systems, a surgeon could not reasonably be criticized for employing any
of these methods because no method was clearly superior. When the locked-screw proximal
humeral plating system was introduced in the United States in 20021-4, there was a widely held
belief that perhaps the situation had changed. Perhaps the locked-screw proximal
humeral plating system was the answer to the problem of the displaced proximal
humeral fracture.
I assume that many readers have seen the apple-fixation
demonstration shown by vendors of certain locked-screw proximal humeral plating
systems. If not, the demonstration is as follows: A plate is affixed to an
apple by means of nonlocking screws. When pulled, the plate is easily separated
from the apple, as the screws pull out of the apple. Then, a plate is affixed
to an apple with locking screws. The plate cannot be pulled off the apple. Instead,
the apple breaks in half. It is easy for a surgeon viewing the demonstration to
substitute in his or her imagination the soft bone of an elderly humeral head
for the flesh of an apple. Indeed, in the shoulder fracture-fixation community,
since the advent of locked-screw proximal humeral plating systems, there has
been a consensus that a lesser amount of malreduction should be accepted and
that many fewer humeral head replacements should be performed.
However, this paper, "Displacement/Screw Cutout After Open
Reduction and Locked Plate Fixation of Humeral Fractures," demonstrates that,
although it is good, this method is no panacea.
To get back to my initial feeling upon reading this paper,
why would I, a surgeon, feel relief at reading this? First, I have had the
experience of seeing loss of fracture reduction in some of my patients in whom
I have used locked-screw proximal humeral plating. I feared that I was the only
one for whom this supposedly nearly perfect fixation failed, and naturally, I
doubted my own judgment and skill. Now I know that I am not alone in this experience.
Second, in my opinion as a surgeon and not as an attorney†, this article's demonstration that locked-screw proximal humeral plating is not
the ideal answer to the problem of displaced proximal humeral fractures means
that this method has not ascended to the position of "the standard of care." In
my opinion as a surgeon and not as an attorney, any of the methods mentioned
above may be used when they have been thoughtfully selected for an actual
patient, and the choice should not be attacked as failing to meet "the standard
of care."
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
†I have earned a Juris Doctorate, but I have not taken the American Bar Association's examination in any state. The opinion stated here is not to be taken as a legal opinion for any jurisdiction or legal advice for any entity. It is the same opinion that I would have had as a surgeon, before I ever set foot in law school.
References
1. Lungershausen W, Bach O, Lorenz CO. [Locking plate osteosynthesis for fractures of the proximal humerus.] Zentralbl Chir. 2003;128:28-33. German.
2. Plecko M, Kraus A. Internal fixation of proximal humerus fractures using the locking proximal humerus plate. Oper Orthop Traumatol. 2005;17:25-50.
3. Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20:602-7.
4. 3.5 mm LCP™ Proximal Humerus Plate Technique Guide. West Chester, Pennsylvania: Synthes (USA); 2002.
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