JBJS -- Letters to the Editor for Südkamp et al., 91 (6) 1320-1328

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Scientific Articles:
N. Südkamp, J. Bayer, P. Hepp, C. Voigt, H. Oestern, M. Kääb, C. Luo, M. Plecko, K. Wendt, W. Köstler, and G. Konrad
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 [Abstract] [Full text] [PDF]

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Electronic letters published:

Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot: Gerhard G. Konrad, MD, Norbert P. Südkamp, MD (5 August 2009)

Does Patient Age Affect Outcome with PHILOS Plates?: James O. Smith, Pradeep Moonot (5 August 2009)

Drs. Konrad and Südkamp respond to Drs. Court-Brown and McQueen: Gerhard G. Konrad, MD, Norbert P. Südkamp, MD (22 July 2009)

Treatment of Proximal Humeral Fractures: Charles M. Court-Brown, MD, FRCSEd(Orth), Margaret McQueen, MD FRCSEd(Orth) (8 July 2009)

Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot 5 August 2009

Gerhard G. Konrad, MD,
Orthopaedic Surgeon
University Hospital Freiburg, Germany,
Norbert P. Südkamp, MD
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Re: Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot

gerhard.konrad{at}uniklinik-freiburg.de Gerhard G. Konrad, MD, et al.

The authors would like to thank Drs. Smith and Moonot for their interest in our study. They raised several points which deserve further comment. We have the following explanations to offer:
An analysis of the complication rate with respect to patient age was initially not performed in the study. However, after reanalyzing the data we separated two groups of patients: Group 1 younger than 60 years (n = 65, 42% of all patients) and Group 2 older than 60 years (n = 90, 58% of all patients). 43 of the 62 complications (69%) were encountered in Group 2.
The mode of failure of the three cases of plate breakage was related to surgical technique. In all three cases, a nonunion of the fracture was present after initial malreduction of the fracture. Due to the nonunion, a stress concentration onto the plate occurred which is biomechanically highly predictive for plate breakage. Therefore the implant breakage was not related to the type of plate and its metallic composition.
Although rates of primary screw perforation into the glenohumeral joint and other technique-related complications were observed in our study, we believe that it is not necessary that these fractures be treated exclusively by a shoulder or upper-extremity specialist. Because of the increasing numbers of proximal humeral fractures more generalists will likely be treating these patients. If a trauma surgeon uses the correct surgical technique a good functional outcome can be expected. However, since these fractures are difficult to treat, a trauma surgeon needs to be well versed in the technique and must have adequate surgical skill and assistance to perform the operation correctly. An appropriate fracture reduction prior to the fixation with the locking proximal humerus plate is indispensable. A final image intensifier check with multiple radiographic views including an axial view is also necessary in all cases.

Does Patient Age Affect Outcome with PHILOS Plates? 5 August 2009

James O. Smith,
Specialty Registrar, Orthopaedics
St. Mary's Hospital, Isle of Wight, United Kingdom,
Pradeep Moonot
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Re: Does Patient Age Affect Outcome with PHILOS Plates?

jsmith{at}doctors.org.uk James O. Smith, et al.

To the Editor:
We read the article by Südkamp et al. (1) with interest. Treatment of these fractures remains controversial, in part due to the scarcity of prospective studies evaluating this technique. This careful multicenter study, with good numbers, lacking in previous papers, helps to define more clearly the indications for the use of the proximal humeral locking plate.
Previous studies have compared the outcome in younger and older patients (2-4). However, they showed differences in the Constant score as well as the rate of complications. This may be due to the small sample size. We would therefore welcome further analysis into complication rates with respect to patient age in the present study.
Discussion of the mode of failure of the three cases of implant breakage would also have been helpful. One of the previous studies reported a case of plate breakage because the plate was applied to the humeral shaft incorrectly (3). Was plate breakage in the present case series related to the type of plate and its metallic composition (titanium or steel) or due to surgical technique?
We also note a high rate (21 patients) of primary screw perforation into the glenohumeral joint. This has not been seen in previous case series (2-4).
Do the authors believe that, due to these reasons, fixation of these fractures using the proximal humeral locking plate should be done by upper limb specialist surgeons?
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. 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 authors, or a member of their immediate families, are affiliated or associated.
References
1. 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;91:1320-8.
2. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Related Res. 2006;442:115-20.
3. Moonot P, Ashwood N, Hamlet M. Early results for the treatment of three- and four- part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint Surg Br. 2007;89:1206-9.
4. 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;75:741-5.

Drs. Konrad and Südkamp respond to Drs. Court-Brown and McQueen 22 July 2009

Gerhard G. Konrad, MD,
Orthopaedic Surgeon
University Hospital Freiburg, Germany,
Norbert P. Südkamp, MD
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Re: Drs. Konrad and Südkamp respond to Drs. Court-Brown and McQueen

gerhard.konrad{at}uniklinik-freiburg.de Gerhard G. Konrad, MD, et al.

The authors would like to thank Drs. Court-Brown and McQueen for their interest in our study. They raised several points which deserve further comment. We have the following explanations to offer: We agree that it is important to define the indications for surgical treatment of proximal humeral fractures, especially because proximal humeral fractures are common and are getting more common as the prevalence of osteoporotic fractures increases. However, the aim of the present study was to evaluate the functional outcome and complication rate after open reduction and internal fixation of proximal humeral fractures with the Locking Proximal Humerus Plate. There was no control group for conservative treatment. Therefore with the data available out of this study it is not possible to determine which fractures will do better with surgical treatment. In our study all fractures either met the indications for operative treatment outlined by Neer, i.e. an angulation of the articular surface of more than 45º or a displacement between the major fracture segments of more than 1 cm, or were unstable when tested with passive motion using an image intensifier. Nondisplaced stable fractures and fractures with minimal displacement and adequate stability as well as fractures involving only the greater or lesser tuberosity were not considered for treatment with the plate. Therefore the patients in our study presumably represent a selection which will end up with a lower Constant score after conservative treatment compared to the patients in the study by Court-Brown and McQueen. In their study, all patients had an impacted valgus fracture (B1.1) of the proximal humerus. The distribution of fracture types according to the AO classification and gender is shown in Figure 1. Also the results for different fracture types is mentioned in the manuscript and there was no significant difference in the Constant score between fracture types according to the AO classification at the final follow-up.

Treatment of Proximal Humeral Fractures 8 July 2009

Charles M. Court-Brown, MD, FRCSEd(Orth),
Professor of Orthopaedic Trauma
University of Edinburgh, Edinburgh, Scotland,
Margaret McQueen, MD FRCSEd(Orth)
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Re: Treatment of Proximal Humeral Fractures

courtbrown{at}aol.com Charles M. Court-Brown, MD, FRCSEd(Orth), et al.

To the Editor:
We read the article by Südkamp et al. (1) with interest. The authors have written yet another paper on the advantages and disadvantages of a locking proximal humeral plate and while we have no doubt that the study was performed well we believe that they have sidestepped the real issue which is who should be treated with these plates.
They report a mean Constant score of 70.6 one year after surgery in 187 patients with proximal humeral fractures. They do not detail the results for different fracture types but our analysis of the paper suggests that about 105 fractures were AO A2, A3 or B1 fractures and it seems reasonable to assume that they achieved better results with these simpler fractures than in the AO B2, B3 and Type C fractures that they also treated. We believe that the results reported by Südkamp et al. are no better than are achieved with non-operative management. In previously published studies (2,3) we documented mean Constant scores of 64, 65 and 72 for AO A2, A3 and B1 fractures one year after non-operative management. The average ages of our groups were 74, 68 and 71 years respectively, these being considerably more than the average age of Dr Südkamp’s patients which was 63 years. Age is obviously very important to outcome. We documented a mean Constant score of 75.7 in patients with B1 fractures who were 60 – 69 years of age compared with 67.1 in patients who were 80 – 89 years of age (2). When age is considered, we believe that there is no evidence that the locking plate actually improves the outcome in most patients.
We do not doubt that there are patients with proximal humeral fractures who benefit from surgery and that the fracture type, age of patient, general mobility and the presence of clinical and social comorbidities influence surgeons in their choice of treatment. However, the literature is deficient in helping us consider which fractures will do better with surgical treatment. This is important as proximal humeral fractures are common and are getting more common as the prevalence of osteoporotic fractures increases. It is important that shoulder surgeons and trauma surgeons start doing more than simply assessing yet another plate.
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. 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 authors, or a member of their immediate families, are affiliated or associated.
References
1. Südkamp N, Bayer J, Hepp P, Voight 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;91:1320-8.
2. Court-Brown CM, McQueen MM. Two-part fractures and fracture dislocations. Hand Clin. 2007:23;397–414.
3. Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg Br. 2002:84;504–8.