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ORIGINAL ARTICLE
Year : 2018  |  Volume : 21  |  Issue : 3  |  Page : 362-366

Is medial calcar continuity necessary in plate osteosynthesis for proximal humerus fractures?


1 Department of Orthopaedic Surgery, Giresun University Medical Faculty, Giresun, Turkey
2 Department of Orthopaedic Surgery, Okmeydani Research and Training Hospital, Istanbul, Turkey
3 Department of Anaesthesiology and Intensive Care, Okmeydani Research and Training Hospital, Istanbul, Turkey

Date of Acceptance11-May-2017
Date of Web Publication09-Mar-2018

Correspondence Address:
Prof. C Z Esenyel
Department of Orthopaedic Surgery, Giresun University Medical Faculty, Giresun
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_400_16

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   Abstract 


Objective: To evaluate the functional and radiological results of patients with and without medial calcar continuity in plate osteosynthesis applied for a proximal humerus fracture retrospectively. Methods: The study included 27 patients to whom plate osteosynthesis was applied because of a proximal humerus fracture between January 2, 2010, and December 30, 2013, at Okmeydanı Research and Training Hospital. Patients were separated into Group A with medial calcar continuity and Group B without medial calcar continuity. On the radiographs taken postoperatively and at the final follow-up examination, measurements were taken of the humeral head height and the humeral neck-shaft angle. The presence of avascular necrosis was recorded. Results: The functional and radiological results of the patients were evaluated after a mean follow-up of 39.1 months. No statistically significant difference was determined between Groups A and B in respect of the postoperative and the final follow-up humeral head height (P > 0.05). No statistically significant difference was determined between Groups A and B in respect of the postoperative and the final follow-up humeral neck-shaft angle (P > 0.05). Plate breakage was seen in one patient without medial calcar continuity. Penetration of the screw into the joint was determined in one patient in Group A and three patients in Group B. No avascular necrosis or infection was seen in any patient. Conclusion: When the surgical process has not damaged the soft tissue and sufficient stability has been achieved, providing calcar continuity is not an absolute condition.

Keywords: Humeral neck-shaft angle, humerus head avascular necrosis, proximal humerus fractures, proximal humerus medial calcar


How to cite this article:
Esenyel C Z, Kalkar I, Adaş M, Dedeoğlu S S, Büyükkurt C D, Cabuk H, Esenyel A E. Is medial calcar continuity necessary in plate osteosynthesis for proximal humerus fractures?. Niger J Clin Pract 2018;21:362-6

How to cite this URL:
Esenyel C Z, Kalkar I, Adaş M, Dedeoğlu S S, Büyükkurt C D, Cabuk H, Esenyel A E. Is medial calcar continuity necessary in plate osteosynthesis for proximal humerus fractures?. Niger J Clin Pract [serial online] 2018 [cited 2022 Nov 29];21:362-6. Available from: https://www.njcponline.com/text.asp?2018/21/3/362/226970




   Introduction Top


As a result of osteoporosis becoming more evident with advancing age, proximal humerus fractures are often seen in the elderly.[1] Depending on the integrity of the shoulder joint capsule, fractures are usually not displaced or only minimally so and therefore the majority of proximal humerus fractures can be followed up conservatively.[2] Displaced fractures require surgery. In appropriate cases, the preferred intervention is open reduction and internal fixation with plate. In osteosynthesis with plate, choice of plate, choice of surgical incision, soft tissue repair, reduction criteria, and placement of the plate and screws are important. The main goal of surgery is to provide stable fixation which will give the least disruption to the blood supply of the fragments, give the least damage to the soft tissue, and allow movement in the shortest possible time. It has been stated in several studies that medial calcar continuity is necessary in surgical reduction, and that the capsule and capsular blood flow sacrificed for full reduction have a negative effect on union.[3],[4],[5]

In this study, the results were evaluated of patients with and without medial calcar continuity in osteosynthesis made with a plate without dissecting soft tissue during surgery for proximal humerus fractures.


   Methods Top


This study was approved by the ethical and research committee of Okmeydanı Training and Research Hospital.

This retrospective study included 27 patients (17 females and 10 males) with a mean age of 57.9 years (range, 29–83 years) who had plate osteosynthesis applied for proximal humerus fracture between January 2010 and December 2013 at Okmeydanı Research and Training Hospital. The patients were grouped into 2 groups as Group A with medial calcar continuity and Group B without medial calcar continuity.

The fractures were classified radiologically according to the Neer classification. Patients with pathological fractures, isolated tubercle fractures, or open fractures were excluded from the study. In the preoperative examination, there were no neurovascular problems in the patients.

In the half-sitting position, a deltopectoral incision was made. When the fracture was reached, reduction was applied manually under fluoroscopy guidance without soft tissue dissection. When the reduction was decided to be sufficient, the plate was placed posterior to the bicipital groove, paying attention to the bicipital groove, and tuberculum majus. Then, under fluoroscopy control, the fracture was fixed by applying screws to the plate which had been initially held with Kirschner wires.

On the radiographs taken postoperatively and at the final follow-up examinations, the measurements were taken as previously defined of the vertical distance between the humerus head and the upper point of the plate [Figure 1] and the humeral neck-shaft angle [Figure 2].[1],[2]
Figure 1: The measurement of the vertical distance between the upper tip of the plate and the upper tip of the humerus head as defined by Gardner

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Figure 2: The measurement of the humerus neck-shaft angle as defined by Agudela

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At the final follow-up examination, the functional status of each patient was evaluated with the DASH and Constant-Murley shoulder score.

Statistical analysis

In the statistical analyses of the study data, SPSS 22.0 software (IBM, Armonk, NY, USA) was used. Descriptive data were stated as mean, standard deviation, median, minimum, maximum, frequency, and ratio values. Distribution of the variables was measured with the Kolmogorov–Smirnov test. In the analysis of the quantitative data, the Mann–Whitney U-test was used. In the analysis of the repeated measurements, the Wilcoxon test was used. In the analysis of the qualitative data, the Chi-square test was used, and when Chi-square conditions were not met, the Fisher's test was used.


   Results Top


The functional and radiological results of the patients were evaluated after a mean follow-up of 39.1 months (range, 24–60 months). According to the Neer classification, 16 patients were Type 3 (Group A - eight patients and Group B - eight patients) and 11 patients were Type 4 (Group A - eight patients and Group B - three patients). A screw was advanced to the medial calcar in four patients in Group A and 5 patients in Group B.

No statistically significant difference was determined between Groups A and B in respect of age and gender distribution of the patients (P > 0.05) [Table 1].
Table 1: Patient characteristics of both groups

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No statistically significant difference was determined between Groups A and B in respect of the postoperative and the final follow-up humeral head height (P > 0.05) [Table 2].
Table 2: Comparison of the postoperative and the final follow-up humeral head height between groups

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In Group A, the final follow-up humeral head height was statistically significantly lower than the postoperative measurement (P< 0.05). In Group B, the final follow-up humeral head height was statistically significantly lower than the postoperative measurement (P< 0.05) [Table 2].

The amount of the decrease in the final follow-up humeral head height compared to the postoperative measurement showed no statistically significant difference between the two groups (P > 0.05) [Table 2].

No statistically significant difference was determined between Groups A and B in respect of the postoperative and the final follow-up humeral neck-shaft angle (P > 0.05) [Table 3].
Table 3: Comparison of the postoperative and the final follow-up humeral neck shaft angle between groups

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In Group A, the final follow-up humeral neck-shaft angle was statistically significantly lower than the postoperative measurement (P< 0.05) [Table 3].

In Group B, the final follow-up humeral neck-shaft angle was statistically significantly lower than the postoperative measurement (P< 0.05) [Table 3].

The amount of the decrease in the final follow-up humeral neck-shaft angle compared to the postoperative measurement showed no statistically significant difference between the two groups (P > 0.05) [Table 3].

In Group A, the mean DASH score was 33.1 and the mean Constant score 74.6, and in Group B, the mean DASH score was 29 and the mean Constant score 67.1.

Bone union was achieved in all fractures. In 1 patient without medial calcar continuity, the plate broke in the early postoperative period and that patient was withdrawn from the study. Penetration of the screw into the joint was determined in 4 patients (Group A, 1 and Group B, 3) and this was removed with an additional surgical procedure in the early postoperative period. No avascular necrosis or infection was determined in any patient.


   Discussion Top


Proximal humerus fractures are the third most frequently seen osteoporotic fracture, and surgical treatment in recent years has increased approximately 4-fold compared to previous years.[1] If surgical treatment is selected for proximal humerus fracture, the main problems to be overcome are achieving reduction of small bone fragments and the continuation of this reduction because of muscle difficulties.[6]

For many years, fractures of 3 or 4 fragments were considered to be poor candidates for both conservative treatment and fixation and Neer recommended arthroplasty for these types of fractures.[7] However, with the development of locking plates, better results have been reported from surgical fixation in elderly patients.[8] In the current study, all the proximal humerus fractures to which plate osteosynthesis was applied were Type 3 and Type 4 according to the Neer classification. However, one of the greatest problems in Type 3 and Type 4 fractures is the difficulty in providing support to the medial calcar.

In the current study, patients with and without medial calcar continuity were examined clinically and radiologically. No statistically significant difference was determined between the groups with and without medial calcar continuity in respect of age, gender, fracture type, and clinical findings. Although the humerus head height decreased by a significant degree in both groups, no difference was found between the groups. The capsule was not dissected during surgery in any patient. The main blood supply of the humerus head is the anterior circumflex artery, but studies have shown that following a fracture, the posterior circumflex artery has come under pressure.[9],[10],[11] As the blood supply reaches the humerus head via the capsule, then the better the capsule is protected during surgery, so the success of the treatment will be increased. In a study by Hertel et al.,[12] it was reported that with an increase in the posteromedial contact area, the blood supply to the humerus head increased and necrosis decreased and there was also stated to be a strong connection between medial support and blood supply.

Considering the importance of medial support, Gardner et al. applied a fibular graft for the restoration of medial support.[13] It was stated that insufficient medial column stabilization in fragmented fractures could be the cause of failure with early reduction loss.[3],[4]

A statistically significant loss was reported in patients without medial calcar support. It was concluded that it was necessary to provide medial calcar support and if reduction is not achieved, support with screws is necessary.[3] In the current study, a screw was advanced to the medial calcar in 4 patients in Group A and 5 patients in Group B. When these patients were examined, no statistically significant differences were determined between them in respect of age, humerus head height, neck-shaft angle, or clinically.

However, in the study by Gardner et al., the patient age distribution between the groups was different and detailed information about the clinical results was not given, thus not providing satisfactory information as to how important medial calcar support is.

In a study by Juan Agedelo et al.,[2] when postoperative radiographs were examined, it was claimed that if head-shaft angle was ≥120°, there would not be any fixation loss but if it were <120° early failure could develop. In other words, it was reported that varus malreduction would lead to early failure. In the current study, the postoperative neck-shaft angle was measured as mean 124.9° in the group with medial calcar continuity and mean 128.5° in the group without medial calcar continuity. Varus malreduction did not develop in any patient.

In a study by Egol et al.,[14] the most frequently seen complication in the application of locking plates was shown to be the screw falling into the joint because of collapse of the humerus head. Lill et al.[15] reported this complication at the rate of 17% and Fankhauser et al.[16] at 10% and in both studies the complication was stated to be connected to the rigidity of the fixation. In the current study, screw penetration was calculated as 14.8%, which was seen to be consistent with literature.

Limitations of this study can be said to be the low number of cases and that it was retrospective. A more extensive prospective study on this subject would produce more reliable results.


   Conclusion Top


Similar clinical and radiological results were determined in the patients with and without medial calcar support [Figure 3]. As the capsule was left intact during surgery, the blood supply was not disrupted. As a result of anatomic locking plates holding the humerus head in all directions, varus malreduction was prevented, metaphyseal contact was protected, and continuation of the blood supply was provided. Thus, the blood supply was provided and successful results were obtained. Protection of the soft tissue and the head-neck angle of >120° can be considered to be more important than medial calcar continuity.
Figure 3: It is seen that a fracture of the proximal humerus fracture treated with an open reduction and internal fixation, and union of this proximal humerus fracture without medial calcar support

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21:185-91.  Back to cited text no. 1
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2.
Agudelo J, Schürmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 2007;21:676-81.  Back to cited text no. 2
    
3.
Huttunen TT, Launonen AP, Pihlajamäki H, Kannus P, Mattila VM. Trends in the surgical treatment of proximal humeral fractures – A nationwide 23-year study in Finland. BMC Musculoskelet Disord 2012;13:261.  Back to cited text no. 3
    
4.
Iannotti JP, Ramsey ML, Williams GR, Warner JJ. Nonprosthetic management of proximal humeral fractures. J Bone Joint Surg 2003;85:1578-93.  Back to cited text no. 4
    
5.
Korkmaz MF, Aksu N, Gögüs A, Debre M, Kara AN, Isiklar ZU. The results of internal fixation of proximal humeral fractures with the PHILOS locking plate. Acta Orthop Traumatol Turc 2008;42:97-105.  Back to cited text no. 5
    
6.
Jo MJ, Gardner MJ. Proximal humerus fractures. Curr Rev Musculoskelet Med 2012;5:192-8.  Back to cited text no. 6
    
7.
Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-103.  Back to cited text no. 7
    
8.
Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am 2009;91:1689-97.  Back to cited text no. 8
    
9.
Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study. J Bone Joint Surg Br 1993;75:132-6.  Back to cited text no. 9
    
10.
Coudane H, Fays J, De La Selle H, Nicoud C, Pilot L. Arteriography after complex fractures of the upper extremity of the humerus bone: A prospective study- preliminary results. J Shoulder Elbow Surg 2000;9:17.  Back to cited text no. 10
    
11.
Trupka A, Wiedemann E, Ruchholtz S, Brunner U, Habermeyer P, Schweiberer L. Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis? Unfallchirurg 1997;100:105-10.  Back to cited text no. 11
    
12.
Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13:427-33.  Back to cited text no. 12
    
13.
Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 2008;22:195-200.  Back to cited text no. 13
    
14.
Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani NC, Zuckerman JD. Early complications in proximal humerus fractures (OTA Types 11) treated with locked plates. J Orthop Trauma 2008;22:159-64.  Back to cited text no. 14
    
15.
Lill H, Hepp P, Rose T, König K, Josten C. The angle stable locking-proximal-humerus-plate (LPHP) for proximal humeral fractures using a small anterior-lateral-deltoid-splitting-approach – Technique and first results. Zentralbl Chir 2004;129:43-8.  Back to cited text no. 15
    
16.
Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 2005;430:176-81.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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