Internal fixation of proximal humeral fractures with locking proximal humeral plate (LPHP) in elderly patients with osteoporosis
Ramchander Siwach
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1
Roop Singh
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Rajesh Kumar Rohilla
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1
Virender Singh Kadian
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1
Sukhbir Singh Sangwan
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Manjeet Dhanda
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R. Siwach (&) 9-J/52,
Medical Enclave PGIMS
, Rohtak 124001, Haryana,
India
1
R. Siwach R. Singh R. K. Rohilla V. S. Kadian S. S. Sangwan M. Dhanda Department of Orthopaedic Surgery
, Paraplegia and Rehabilitation, Pt. B.D. Sharma PGIMS, Rohtak, 124001, Haryana,
India
Background Different operative techniques used for treating displaced proximal humeral fractures could result in malunion, non-union, osteonecrosis of humeral head, loosening of screw and loss of reduction particularly in comminuted and osteoporotic fractures. Locking compression plate (LPHP) has been proposed for open reduction and internal fixation of these fractures and is associated with less complication rate. Materials and methods We prospectively assessed the functional outcome and the complications after an average follow-up of 24.9 months in 25 patients of proximal humeral fractures with osteoporosis. Mean age was 62 years. Using AO classification, 48% were type A and 52% type B. Results Mean constant score was 80 points. According to constant score, 28% had excellent outcome, 64% had good functional outcome, and 8% had moderate outcome. When the results were related to grades of osteoporosis, grade IV osteoporotic fractures had highest average Constant-Murley score (83 points, range 78-88 points), followed by grade III osteoporotic fractures (80 points, range 71-92 points), followed by grade II osteoporotic fractures (78 points, range 66-88 points). Varus malalignment and subacromial impingement were observed in 8% patients. Loosening of implant and loss of reduction were observed in 4% patients. Superficial infection was observed in 4% patients. Conclusions Locking compression plate (LPHP) is an advantageous implant in proximal humeral fractures due to angular stability, particularly in comminuted fractures and in osteoporotic bones in elderly patients, thus allowing early mobilization.
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Proximal humeral fractures are the third most common
fracture in the elderly patients [1]. The incidence of
proximal humeral fractures is increasing, probably due to
the ageing society and the associated increase in the
incidence of osteoporosis [1, 2]. Conservative treatment of
displaced proximal humeral fractures may result in
unacceptable deformity and stiffness of the shoulder [3, 4].
Different operative techniques used for treating displaced
proximal humeral fractures can result in malunion,
nonunion and osteonecrosis of humeral head [57].
Comminuted fractures and older patients presenting with
weakened bone from osteoporosis present additional
challenge to treatment [2]. As proximal fragment is too small to
accommodate minimum of three screws, loosening of
screws and loss of reduction may occur with conventional
implants [6, 8]. Poor rotational and angular stability can
lead to a partial loss of reduction into varus or retro flexion,
resulting in an unsatisfactory functional outcome [3].
For full functional recovery of shoulder anatomical
reduction, stable fixation and early mobilization are
required. Recently, locking proximal humeral plate
(LPHP), providing greater angular stability, has been
proposed for operative fracture treatment [9]. Its theoretical
advantage is better anchorage of screws in osteoporotic
bone. Because of the good fixation, there is potential of
enhanced stability that could allow early mobilization.
Additionally, they can be inserted using a minimally
invasive technique without additional trauma to the soft
tissues [10].
The objective of this study was to evaluate the clinical
outcome and complications of LPHP in managing
displaced proximal humeral fractures with osteoporosis in
elderly patients.
Materials and methods
This was a prospective study performed at Department of
Orthopaedics, PGIMS, Rohtak between April 2003 and
May 2007. A total of 25 patients (12 males and 13 females)
with displaced proximal humeral fractures were operated
using LPHP.
The inclusion criteria into the study were
1. Closed displaced two- and three-part proximal humeral fractures in adults with osteoporosis.
2. Failed conservative treatment (unsatisfactory position).
3. Patients without neurological deficit.
4. Grade IIV osteoporosis as per Singhs index [11].
Open fractures, pathological fractures, and four-part
fractures were excluded from study.
All proximal humeral fractures met the indications for
the operative treatment outlined by Neer [4] i.e. an
angulation of articular surface of more than 45 , a displacement
between the major fracture segments more than 1 cm, or a
fracture with valgus impaction [15]. Two-part fractures
involving only the greater or lesser tuberosity were not
included in this study, since they were managed by screw
fixation. Mean age was 62 years (range 5469 years).
Mean follow-up time was 24.9 months (range 15
28 months). Using plain radiographs, all fractures were
classif (...truncated)