RESULTS OF OSTEOSYNTHESIS OF PROXIMAL HUMERUS FRACTURES WITH INTRAMEDULLARY NAIL AND ADDITIONAL SUTURE FIXATION OF TUBEROSITIES Egiazaryan K.A., Ratyev A.P., Tamazyan V.O., Glazkov K.I., Ershov D.S.
Pirogov Russian National Research Medical University,
Moscow, Russia
Reutov Central City Clinical Hospital, Reutov, Moscow region, Russia
The proximal humerus fracture (PHF) takes the third place in incidence in older people, and is exceeded in abundance only by hip and distal radius fractures. Its incidence is only 4-5 % of bone fractures of the whole body [1, 2]. It is widely thought that such fractures are determined by osteoporosis and are mainly associated with increasing number of injuries in older women with a fracture in the metaphyseal zone [3]. The main cause of trauma is falling – 75 % of women in the postmenopausal period [2]. From other side, PHFs are more often identified in the subgroup of older persons with normal health and working capability [3].
In comparison with two-fragmental fractures without displacement and good prognosis after conservative treatment, the management of displaced fractures is a disputable issue. Conservative treatment of these fractures can lead to delayed union of the humerus, false joints, joint stiffness and posttraumatic arthrosis, resulting in disability [5].
Various fixators were offered for PHF, including pins, locked plates and intramedullary nails. Although there is no best choice, most specialists agree that minimally invasive intervention and adequate fixation are the main properties of any internal fixing device [6].
Currently, intramedullary fixation of proximal humerus is more common. It is related to improvement in the technology, evolution of implants and better understanding of shoulder joint anatomy. However errors and complications after use of nails still exist [7].
Objective – to evaluate outcomes of surgical treatment of patients with proximal humerus fractures with use of intramedullary locked fixation, using the standard technique with closed reposition and with the offered technique of semi-opened reposition and additional suture fixation of tuberosities.
MATERIALS AND METHODS
The study was conducted in compliance with the principles of World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and the Rules for Clinical Practice in the Russian Federation (the Order of Health Ministry of RF, 19 June 2003, No.266), with the written consent for participation in the study and approval from the ethical committee of Pirogov Russian National Research Medical University (the protocol 66, 19 February 2007).
There were two groups of patients with PHFs. The patients were treated in the traumatology and orthopedics unit in Reutov Central City Clinical Hospital in 2010-2017. The first group included 47 patients who received intramedullary fixation with use of closed technique of introduction of the nail. The second group included 42 patients who received the intramedullary fixation with semi-opened technique of reposition and additional soft tissue stabilization of humeral tuberosities.
The first group was estimated on the basis of retrospective data for the period of 2010-2014. The treatment results one year after surgery were examined in 35 patients among 47. Women prevailed (26 patients, 74.3 %), the mean age of 52.8 (22-79). As for patterns of fractures, the group included only two-fragmental fractures at the level of surgical neck of the humerus according to Neer classification. For this period, we did not make any attempts of osteosynthesis of three- and four-fragmental fractures with use of nails. The main feature of the group was a technique of osteosynthesis – the standard technique of closed reposition of a fracture under control of electronic optical converter (EOC) and antegrade introduction of the nail. The universal humerus nail (UHN) without angle stability of locking screws was used in 7 cases. 28 patients received short nails of generation 1-2 with the curved proximal part of the nail. The operations were conducted by different surgeons.
Based on the results in the group 1 and after conclusions, we changed the management techniques for patients with PHF. In 2014, we refused from closed reposition in intramedullary fixation of PHF. We started to use the semi-opened reposition with additional soft tissue stabilization of humeral tuberosities for achievement of good results. Two invention patents of RF were received (No.2673115 and No.2673146). Only nails of the second generation with the curved proximal part and possibility for locking proximal screws were used for this technique.
In the second group, the results were examined in 35 among 42 patients. There were more women (27 patients, 77.1 %). The mean age was 56.9 (23-70). According to fracture pattern, the group included two-fragmental fractures at the level of surgical neck of the humerus – 7 patients (20 %), three-fragmental (surgical neck and greater tubercle) – 24 patients (68.6 %), four-fragmental – 4 patients (11.4 %) according to Neer. All surgical interventions were conducted by the surgical team.
The offered technique of semi-opened intramedullary fixation of PHF was realized as described below. The anteriolateral approach is made [8]. A lineal incision (5-6 cm) is made from the anteriolateral angle of acromion in parallel manner to deltoid muscle fibers, not reaching the plane of the submuscular nerve. After opening the deltoid muscle, the region of sulcus intertubercularis is visualized, as well as the more distal part – the region of adherence of the greater pectoral muscle tendon to the humerus diaphysis. Then, parallel to the CLB tendon, the transverse humeral ligament and the interrotatory interval (joint capsule) between the supraspinous muscle tendon and the subscapular muscle tendon are dissected. This incision gives the approach to CLB tendon, which is located in the sulcus intertubercularis. CLB tendon is sutured with non-biodegradable sutures with two encircling stitches to the proximal border of the greater pectoral muscle tendon (tenodesis) near the place of adherence to the humerus for prevention of changes in biceps length. Then the curved scissors are used for tenotomy of CLB tendon near the region of fixing to cavitas glenoidalis scapulae. The free end of the tendon of CLB is dissected more proximal than tenodesis by 0.5-1 cm. After dissection of the intracapsular part of CLB tendon, reposition of humerus fragments simplifies, and a possibility for visual and palpatory control of articular surface of the head in its fracture appears. Then the tendons of supraspinal and infraspinous muscles are sutured with two stitches over the distance of 1-1.5 cm from site of fixing to greater tubercle of the humerus. Traction of stitches enables the manipulation with fragments and reposition under control of EOC. Initially, lateral and distal traction of sutures is realized from the tendons of supraspinous and infraspinous muscles for reposition of greater tubercle. Traction of sutures from the subscapular muscle tendon can control the rotation of the head along the axis of the humerus. During traction of sutures and rotation of the humerus head (depending on varus or valgus displacement) in the required direction, an incision (1-1.5 cm) is made longwise the fibers of the supraspinous muscle tendon. The incision provides the approach to the top of the humerus, where a hole for introduction of the nail is made with the awl.
Despite of the curved nail, we used the medial point of introduction of the nail, which has some advantages: 1) preservation of the supraspinous muscle tendon; 2) medial location of proximal part of the nail in the humerus head preserves the higher amount of bone substance in the lateral part (“lateral bony bridge”), with additional increasing ability to resist the varus shifting forces; 3) in case of fractures affecting the great tubercle , a sudden introduction of the nail into the fracture site can be prevented; 4) after correct introduction of the nail, the proximal part can increase the stability of the construct, with potential resistance to varus forces, and being so called “proximal anchor point”; 5) if the enter point was chosen correctly, then balancing of the head and diaphysis along the axis should happen automatically during introduction of the nail.
Under EOC control, the greater and lesser tubercles are fixed with proximal locking screws, and the nail is fixed with the locked screw in the diaphysis. The sutures, which are conducted through the tendons, are fixed to the heads of the proximal screws. The sutures, which are conducted through the superspinous and infraspinous muscles, are fixed to the screws in the site of greater tubercle. The sutures, which are conducted through the subscapular muscle tendon, are fixed to the screw, which is inserted through lesser tubercle. The ends of each suture are fixed after figure-of-eight suture. Then the layer-by-layer suturing of the wound is carried out, and the sutures are applied onto the skin.
The operated extremity is fixed onto the supporting dressing during 3-4 weeks. Passive training of movements in the shoulder joint was initiated under supervision of the exercise therapy physician beginning from the second day after surgery.
The X-ray control was conducted 4, 12, 26 and 52 weeks after surgery. The treatment results were estimated after 12 months from the surgery.
CSS was used as the objective score (more points mean better functional outcome), Quick Dash Score (QDS) – as subjective one (lower amount of points means better functional outcome) for estimation of results. CSS results were estimated as excellent with more than 90 points, good – 90-80, satisfactory – 79-70, poor – < 70. QDS was estimated: 0-14 – excellent function, 15-29 – good, 30-59 – satisfactory, > 60 – poor.
The statistical analysis of the results was conducted with Excel and the calculators (www.medstatistic.ru). The quantitative data was presented as absolute values, mean arithmetic (M), standard deviations (σ) and mean error in mean arithmetic (m); qualitative data – relative values in percentage. The critical level of significance (α) for testing the statistical hypotheses was 0.05. Student’s test (t) for independent samples was used in case of confirmation of normal distribution of values. P value < 0.05 was considered as statistically significant.
RESULTS
The point of entry of the nail was the zone in the plane of anatomical neck of the humerus on the border between articular surface of the head and the top of greater tubercle in all surgeries in the first group of patients. It was the negative feature for osteosynthesis in this group. As for complications, we should mention the migration of screws owing to absent fixation in some models of nails (4 cases, 11.4 %). Subsequently, failure of fixation appeared in two patients at the background of osteoporosis and formation of false joint of surgical neck of the humerus. High position of the proximal end of the nail promoted the development of impingement syndrome in 4 patients (11.4 %). The nail instability in the proximal fragment caused the secondary varus displacement of the humerus head and fracture union in this position (7 cases, 20 %). Insufficient stability of the construct in the osteoporotic bone was determined by low density of the bone in the lateral part of the head. Also it was worsened by the lateral point of entry. It also caused the development of persistent pain and joint stiffness (3 cases, 8.6 %) due to injury to the site of fixation of the supraspinous muscle tendon during introduction of the nail.
In the second group, we did not find any complications, which were common for the first group. However a complication appeared which was common for multi-fragmental fractures of PHF. In case of four-fragmental fracture in the patient (age of 42) one year after surgery, we observed the radiological picture of aseptic necrosis of the humerus head. We relate this complication to the pattern of the fracture, the injury mechanism (a road traffic accident) and time from the injury to surgery – 11 days (the injury happened outside the borders of the Russian Federation). Despite of this complication, Constant Shoulder Score (CSS) was 78, the Disabilities of the Arm, Shoulder and Hand Score (QDS) – 15.9, i.e. a satisfactory outcome.
The offered technique increases the accuracy of reposition and stability of main fragments of PHF owing to the semi-opened surgical approach. With the anteriolateral approach, one can estimate and perform the correct point of entry of the intramedullary nail. Manipulations with low traumatic effect sutures and high accuracy provide the reposition of tubercles and correction of the head subluxation. Realization of reposition can be simplified by means of tenotomy of the CLB tendon, resulting in absence of a secondary dislocation of fragments after osteosynthesis. Stability of fixation and neutralization of forces of rotator muscles is provided by soft tissue stabilization of rotator tendons on the screw tops. Perfusion and bone mass of the humerus head are preserved by means of use of sutures, but not metal tools. Reposition without metal devices prevents the damages of vascular and neural structures and articular surfaces of the humerus head and the scapula. As result, the surgery time and tissue damage reduce since the amount of used tools decreases.
On the average, the surgical intervention was conducted 5 days after trauma. The mean duration of surgery was 59.1 min (47-72) in the first group, 55.4 min (40-75) in the second one. The decrease in surgery time in the second group was associated with semi-opened reposition (i.e. better one), absence of time losses for mounting and removal of temporary pins for reposition, and also due to absence of X-ray control for some stages of reposition. Despite of presence of patients with three- and four-fragmental fractures in the second group, it did not influence on the increase in surgery time; it is also associated with appropriate control of each stage of surgery through the anteriolateral approach.
In the first group, the mean CSS was 73.6, QDS – 24. In the second group, CSS was 93.1, QDS – 4.7. The tables 1 and 2 show the results of treatment.
Table 1
Distribution of results in the first group
|
Results |
CSS |
QDS |
||
|
Amount of patients |
Amount of points M ± σ (m) |
Amount of patients |
Amount of points M ± σ (m) |
|
|
Excellent |
3 |
92 (0) |
12 |
9.7 ± 3.1 (0.9) |
|
Good |
16 |
82.6 ± 0.9 (0.22) |
9 |
15.9 (0) |
|
Satisfactory |
7 |
72.3 ± 3.9 (1.5) |
12 |
36.35 ± 3.3 (1) |
|
Poor |
9 |
52.5 ± 11.3 (3.8) |
2 |
72.75 ± 6.4 (4.5) |
|
Total: |
35 |
73.6 ± 14.8 (2.5)
|
35 |
24 ± 17 (2.9)
|
Table 2
Distribution of results in the second group
|
Results |
CSS |
QDS |
||
|
Amount of patients |
Amount of points M ± σ (m) |
Amount of patients |
Amount of points M ± σ (m) |
|
|
Excellent |
27 |
96.6 ± 3.0 (0.6) |
33 |
4 ± 4.3 (0.74) |
|
Good
|
6 |
82.7 ± 1.0 (0.4) |
2 |
15.9 (0) |
|
Satisfactory |
2 |
78 (0) |
- |
- |
|
Poor |
- |
- |
- |
- |
|
Total: |
35 |
93.1 ± 7.0 (1.2) |
35 |
4.7 ± 5.0 (0.8) |
When comparing the result of treatment in the first and second group according to CSS, Student’s test was 7.03. The differences were statistically significant (p = 0.00). After comparing the treatment results in both groups using QDS, Student’s test was 6.42. The differences were statistically significant (p = 0.00).
Therefore, the second group demonstrated better results for use of the offered technique. The higher amount of excellent and good values of QDS was observed as compared to CSS. Possibly, this fact was related to the fact that QDS do not include some objective values such as abduction angle, flexion angle and others. When estimating their recovery after trauma, patients more orient to everyday capabilities, but not to real angles of motions.
DISCUSSION
Intramedullary fixation with the nail and locked screws is a quite rational type of osteosynthesis since it provides several theoretical advantages as compared to the plate [9]. In 2013, Kogan P.G. et al. [10] considered the closed locked intramedullary osteosynthesis as one of the most efficient techniques for treatment of comminuted fractures of the proximal humerus. Murylev et al. [11] called the development of the locked nail for the proximal humerus as revolution in intramedullary fixation of PHF [11]. However they believed that reposition should be closed, under X-ray control, without opened recovery of anatomy. After achievement of better results in the patients in the second group, we refused to use the plates for PHF fixation in our unit since 2016. According to our opinion, intramedullary fixation is better than external fixation for such fractures.
In 2002, Cuny et al. [12] reported on the use of Telegraph nail for proximal humerus fractures. In contrast to other constructs and techniques, it was the direct technique, and the authors recommended the anteriolateral approach through the medial and well vascularized part of the rotator cuff. Also they reported on the results of 64 nails in the first year. The results were favorable, including three- and four-fragmental fractures. The further development of the technique was the practical implementation of the direct nails of 3rd generation in combination with soft tissue stabilization of tubercles along with nails of 2nd generation.
In 2009, Blum et al. [13] introduced and accentuated the term for proximal humerus fractures. They presented a report on 151 proximal humerus fractures, which were fixed in the manner different from standard locking. Their patients demonstrated the average Constant score values – 75.3. Similar results were in a study by Kongrad G. et al [14]. The presence of angle stability of screws in the nail is considered by us as a very important factor for achievement of a good result of treatment. angle stability intramedullary nails
The results of the study by Bondarenko P.V. et al. show the high efficiency of the short direct intramedullary nail for two- and three –fragmental fractures of the humerus [15]. In 2015, C. Cuny et al. showed the excellent results of surgical management of three-fragmental fractures of the proximal humerus with use of intramedullary fixators of the third generation [16].
When comparing the results of two studies with similar number of patients and their characteristics [17, 18] with our results, we received the higher amount of good and excellent estimates and lower number complications in the second group.
With development of low invasive techniques, some studies appeared which mentioned some negative moments of closed reposition of fractures. Mittlmeier W.F. et al. [19] reported on 59 complications in 115 patients. The most common complication was screw migration (26 of 59). The authors do not attract attention to the necessity for more proper fixation of tubercles and to improvement in the technique of screw fixation for prevention of this complication. The similar amount of complications (39 %, 26 of 61 patients) was noted in the report by Witney-Lagen C. et al. [20]. The highest amount (7 of 26) was presented by impingement syndrome, which required for removal of the nail. The second most common complication was migration of the greater tubercle and absence of its consolidation. With time, the authors gave more attention to fixation of the tubercle and more proper realization of this stage of surgery.
However the nail was not the single factor which had influenced on improvement in treatment results. Also the opinions concerning stability of fragments in PHF have changed. The improvement in treatment results after additional fixation of tubercles with use of sutures is confirmed by multiple researches [21, 22]. Prudnikov D.O. et al. [23] gave their attention to the fact that minimal displacement of fragments was related to serious functional disorders, and fixation with only screws was inappropriate and gave worse results in comparison with tensioned eight-shaped loop. According to our observations, stability of tubercles after osteosynthesis allows earlier initiating the training of movements in the shoulder joint and without danger of loss of primary reposition in the postsurgical period.
The disputable issue is management of three- and four-fragmental fractures with consideration of possible development of avascular necrosis of capitellum in such patients. In the modern literature, the proportion of avascular necrosis after fixation with intramedullary nails is 4 % on average [17, 18, 24, 25]. In case of necessary prosthetics for this category of patients, it is extremely important to preserve the vitality of elements of the rotator cuff, resulting in decreasing size of the prosthesis, also up to limited change of only articular surface of the humerus head. However not all patients require for prosthetics in case of avascular necrosis of the humerus head since it is also non-progressing and does not cause strong pain or functional deficiency [26]. In our study, the single patient with avascular necrosis of the humerus head is satisfied with the achieved result and refused from prosthetics.
One should note that the second group did not demonstrate such complications as joint stiffness and persistent pain, which are common for PHF. We relate such results to stability of tubercles and tenodesis (or tenotomy) of CLB tendon since it is known as the persistent source of pain feelings [27, 28]. All above-mentioned facts gave the possibility for initiation of early passive training in the shoulder joint with absent pain.
CONCLUSION
The results of the study show the high reliability and efficiency of the offered technique of osteosynthesis. The use of the intramedullary nail with additional soft tissue stabilization of tubercles is possible for all types of PHF. The offered technique should be considered as the choice method for older patients since it leads to high stability of fixation with low traumatic potential for tissues.
The positive side of the study is the very low incidence of complications in the second group of patients. It accentuates the low number of patients operated with this technique. It is important to consider some short term results. The perspective for development of the study is gradual shift to use of nail of 3rd generation in combination with soft tissue stabilization of tubercles.
One can state that the increase in number of treated patients and follow-up of long term results demonstrate all positive and negative sides of the technique.
Information on financing and conflicts of interests
The study was conducted without sponsorship. The authors declare the absence of any potential conflicts of interests relating to publication of this article.