Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Julie Y. Bishop, MD, and Christopher T. Donaldson, MD*,
Ohio State University Department of Orthopaedics, Columbus, Ohio
Posted June 2009
The purpose of this prospective, multicenter, observational
study (Level IV, therapeutic study; a prospective case series) was to evaluate
functional outcomes and complication rates after open reduction and internal
fixation of proximal humeral fractures with use of a locking proximal humeral
plate. One hundred and eighty-seven patients from nine international trauma
units were treated with a proximal humeral locking plate for a proximal humeral
fracture. The average patient age (and standard deviation) was 62.9 ± 15.7
years. Displaced surgical neck, three-part, and four-part unstable proximal
humeral fractures were included in the study. The Constant score was calculated
at the three-month, six-month and one-year follow-up visits, and the Disabilities
of the Arm, Shoulder and Hand (DASH) score was determined for the injured and
contralateral extremities at the one-year follow-up. One-year follow-up was
obtained for 155 (83%) of 187 patients. The authors reported a significant
increase (p < 0.05) in the mean range of motion of the shoulder and the mean
Constant score between the three-month, six-month, and one-year follow-up
examinations. One year after surgery, the mean Constant score was 70.6 for the
injured side compared with 83.0 for the contralateral side. The mean DASH score
was 15.2. No significant difference in outcomes was noted, regardless of
fracture pattern. The reported complication rate was high, with sixty-two
complications encountered in fifty-two (34%) of 155 patients. Thirty-four (55%)
of the sixty-two complications were reported as directly related to the initial
surgical procedure.
The major strengths of this study include the high number of
enrolled patients and the large amount of follow-up data obtained. Although the
study was essentially a case series, the data were collected prospectively and
the fixation construct used was consistent between all study centers. The statistical
analysis performed was thorough, and patients were assessed clinically,
functionally, and radiographically for complications. A direct assessment of patient
outcomes and a candid presentation of complications were offered.
Weaknesses of the study include the low evidence level (Level
IV) and lack of randomization technique. However, it is understandable that the
authors did not want to randomize patients to a technique that has been
documented to be associated with poor outcomes. Additionally, despite the use
of a uniform fixation construct at all centers, differences in surgical technique,
surgeon skill level, and patient selection remain uncontrolled confounding
variables. Also, because Neer's criteria (which are necessarily
subjective) were used to determine displacement and fracture pattern stability, the
interpretation may be limited by poor intraobserver and interobserver reliability.
Such limits are especially applicable in light of the fact that the authors
reported variability of radiographic views and quality among the centers. Lastly,
although nine international trauma centers were included in the study and all
surgeons reported adequate locking plate experience, it is unclear how familiar
each surgeon was with proximal humeral fracture treatment. No information
regarding the volume and/or complication rates of the individual surgeons was
reported.
This study provides useful information regarding a difficult
surgical problem, the unstable osteoporotic proximal humeral fracture, for
which many different surgical techniques with high complication rates and poor
outcomes have been reported1-4. The ideal treatment for this fracture
type has yet to be determined, leaving many options available. Although this
study did not prove that this technique was more successful than other
techniques, it did provide one-year follow-up on a large number of patients who
were treated with the proximal humeral locking plate. Few prospective clinical
studies have described results after locking plate fixation, and most have been
reports on a small number of patients5-7. Thus, this paper
represents an important contribution to the literature. Additionally, the fact
there was an improvement in functional and clinical outcome a year after
surgery can be useful information when counseling patients.
However, despite the good functional outcome reported in
this paper, the high rates of complications (34%) and return to surgery (19%) are
concerning. Although one criticism of the paper could be the variability in
surgical technique and surgeon skill level involved in treating proximal humeral
fractures, it is unrealistic to expect the majority of these fractures to be
exclusively treated by a shoulder and/or upper-extremity specialist. A Finnish
study cited in the paper8 estimates that the number of these fractures
will triple by the year 2030. Thus, more generalists will likely be treating
these patients, and, in this regard, the results are more applicable to this
treating population.
It is understood, however, that these fractures are
difficult to treat and that there is no one ideal surgical solution. Yet,
failures related to improper positioning of the plate and screw penetration of
the humeral head are technique-related complications and, arguably, avoidable.
Additionally, reported failures related to loss of fracture reduction and plate
pullout can also be technique related. Results of this study only reinforce the
tenet of appropriate fracture reduction prior to fixation, and this tenet should perhaps be applied even more strictly in the
setting of powerful locking plate use.
Additional information, not mentioned in this paper, such as
head-shaft angle of the final construct, might have been helpful in allowing
the reader to identify complications driven by technical error compared with
those related to fracture difficulty. In a retrospective review of 153 patients
in whom a displaced proximal humeral fracture was treated with a proximal humeral
locking plate, Agudelo et al.9 noted that, when loss of fixation
occurred, it was primarily in the presence of varus malreduction. They
recommended a head-shaft angle of >120° to maintain fixation and reduction. While
the authors of the current study encourage the use of correct surgical
techniques to avoid complications, more information that would allow the reader
to identify why such complications occurred in the study would have been
helpful.
In summary, this prospective case series adds to our
knowledge base regarding outcomes and complications associated with the use of
proximal humeral locking plates for unstable, displaced proximal humeral
fractures. The reported high complication rate highlights the fact that the
ideal treatment type for these difficult fractures is indeed controversial and
yet to be determined and that concomitant osteoporosis adds to the difficulty
of treating these fractures. Meticulous intraoperative technique and scrutiny
with appropriate, multiple radiographic views are necessary to avoid intraoperative
errors. By avoiding complications through the use of vigilant surgical
technique, good functional outcomes can be obtained with the use of a proximal
humeral locking plate.
*Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
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