Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures
- 15 Downloads
Only a few reports compare the mid- and long-term outcome of the minimally invasive deltoid split (MIDS) with the classic anterior deltopectoral (DP) approach for osteosynthesis in proximal humeral fractures. This study compared the mid-term functional and the radiological results in patients with proximal humeral fractures undergoing osteosynthesis with the proximal humeral internal locking system (PHILOS™).
All patients undergoing osteosynthesis between 2008 and 2015 were clinically and radiologically examined with a minimal follow-up period of 1 year. Functional outcomes were analyzed using the DASH- and Constant Shoulder Scores (CSS). Radiological results were analyzed using a newly developed score.
Thirty-nine patients underwent PHILOS™ osteosynthesis with the MIDS and twenty-three with the DP approach. Follow-up time was 41 months in the MIDS group and 62 months in the DP group, respectively. The median CSS was similar with 79 points in the MIDS group and 82 points in the DP group (p = 0.17). The MIDS group showed a significant lower power measurement in the CSS. In four-part fractures, a substantially lower CSS in absolute numbers in the MIDS group was detected. The median DASH score was 26.7 points in the MIDS group and 25.8 points in the DP group (p = 0.48). There was no difference in the radiological score. More patients with partial avascular necrosis (AVN) were found in the MIDS group, most with three- and four-part fractures. However, this was not statistically significant. Morbidity was similar between groups.
The results of the two surgical approaches are statistically comparable. Some differences such as a lower power measurement in the MIDS group, a higher partial AVN frequency and more plate removals are observed. In four-part fractures, the CSS was lower in the MIDS compared to the DP cohort. The MIDS technique might not be a solution for all fracture types, and the surgeon should be careful to analyze the morphology of the fracture before deciding upon the approach. Four-part fractures might be better treated with a DP approach.
KeywordsProximal humerus fracture Surgical approach Minimally invasive Deltopectoral Mid-term Long-term Locking plate
The authors thank Ms. T. Glass for performing the statistical analyses, Ms. P. Heeb, Scientific Assistant, for her support in recruiting the patients and organizing the follow-up appointments, and Ms. C. Vines, MD, for the English language revision.
Compliance with ethical standards
Conflict of interest
Joëlle Borer, Arby Babians, Jochen Schwarz, Silke Potthast, Marcel Jakob, Philipp Lenzlinger, and Urs Zingg declare that they have no conflict of interest.
- 1.Lippuner K, Popp AW, Schwab P, Gitlin M, Schaufler T, Senn C, et al. Fracture hospitalizations between years 2000 and 2007 in Switzerland: a trend analysis. Osteoporos Int. 2011;22(9):2487–97.Google Scholar
- 2.Baron JA, Karagas M, Barrett J, Kniffin W, Malenka D, Mayor M, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7(6):612–8.Google Scholar
- 3.Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M, Vuori I. Osteoporotic fractures of the proximal humerus in elderly Finnish persons: sharp increase in 1970–1998 and alarming projections for the new millennium. Acta Orthopaed Scand. 2000;71(5):465–70.Google Scholar
- 4.Neer CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am Vol. 1970;52(6):1077–89.Google Scholar
- 5.Neer CS. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am Vol. 1970;52(6):1090–103.Google Scholar
- 6.Habermeyer P. Die Humeruskopffraktur. Der Unfallchirurg. 1997;100:820–37.Google Scholar
- 7.Moonot P, Ashwood N, Hamlet M. Early results for treatment of three- and four-part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint Surg Am Vol. 2007;89(9):1206–9.Google Scholar
- 8.Acklin YP, Jenni R, Walliser M, Sommer C. Minimal, Invasive. PHILOS((R))-plate osteosynthesis in proximal humeral fractures. Eur J Trauma Emerg Surg. 2009;35(1):35–9.Google Scholar
- 9.Lin T, Xiao B, Ma X, Fu D, Yang S. Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures. BMC Musculoskelet Disord. 2014;15:206.Google Scholar
- 10.Liu K, Liu PC, Liu R, Wu X. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. Med Sci Monit. 2015;21:496–504.Google Scholar
- 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(1):21–8.Google Scholar
- 12.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(5):1364–70.Google Scholar
- 13.Vijayvargiya M, Pathak A, Gaur S. Outcome analysis of locking plate fixation in proximal humerus fracture. J Clin Diagn Res. 2016;10(8):RC01–5.Google Scholar
- 14.Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472(5):1576–85.Google Scholar
- 15.Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987(214):160–4.Google Scholar
- 16.Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602–8.Google Scholar
- 17.Ficat RP. Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. J Bone Joint Surg Br Vol. 1985;67(1):3–9.Google Scholar
- 18.Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008;22(2):132–7.Google Scholar
- 19.Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg Am Shoulder Elbow Surg. 2001;10(5):421–7.Google Scholar
- 20.Visser CP, Tavy DL, Coene LN, Brand R. Electromyographic findings in shoulder dislocations and fractures of the proximal humerus: comparison with clinical neurological examination. Clin Neurol Neurosurg. 1999;101(2):86–91.Google Scholar
- 21.Roderer G, Erhardt J, Kuster M, Vegt P, Bahrs C, Kinzl L, et al. Second generation locked plating of proximal humerus fractures—a prospective multicentre observational study. Int Orthop. 2011;35(3):425–32.Google Scholar
- 22.Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg Am Shoulder Elbow Surg. 2004;13(4):427–33.Google Scholar
- 23.Kruithof RN, Formijne Jonkers HA, van der Ven DJC, van Olden GDJ, Timmers TK. Functional and quality of life outcome after non-operatively managed proximal humeral fractues. J Orthop Traumatol. 2017;18(4):423–30.Google Scholar
- 24.Koljonen PA, Fang C, Lau TW, Leung F, Cheung NW. Minimally invasive plate osteosynthesis for proximal humeral fractures. J Orthop Surg. 2015;23(2):160–3.Google Scholar