View of Treatment of Three or Four Part Fracture Proximal Humerus: Plate Fixation versus Percutaneous K-wire

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Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13601 – 13612 Received 10 March 2021; Accepted 22 March 2021.

Treatment of Three or Four Part Fracture Proximal Humerus: Plate Fixation versus Percutaneous K-wire

Mohammed Othman Mohammed Abdurabbah¹,Yousof Mohamed

MohamedKhera²,Ahmed Mohamed Ahmed Nahala³,and Hossam Fathi Mahmoud

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1Faculty of Medicine – Omar Almuktar University – Libya. ²Professor of Orthopedic

Surgery,Faculty of MedicineZagazigUniversity. ³Ass. Professor of Orthopedic Surgery,Faculty of Medicine Zagazig University. ⁴Lecturer of Orthopedic Surgery, Faculty of

Medicine Zagazig University. Correspondingauthor:Mohammed Othman Mohammed Abdurabbah

Email :[email protected]

Abstract

Background:Proximal humerus fractures are one of the commonest fractures occurring in the skeleton. They account for approximately 4 – 5% of the all fracture. Recent trends are shifting away from open reduction and massive internal fixation (by plates and screws) toward closed reduction and percutaneous fixation as this method is less invasive soft tissue damage and minimal risk of iatrogenic avascular necrosis.

Aim of the study:To compare functional outcomes and complications after open reduction and internal fixation of proximal hummers fractures (3 and 4 Neer classification) by plate (PHILOS) versus percutaneous K- wires fixation.

Patients and methods: This study was conducted on 30 patients with mean age 43 years old, range from 18 to 55 with 3- and 4-part fractures according to Neer's classification, patient was randomized to either (group I) includes 15 patients who were treated with open reduction and internal fixation and (group II) who were treated by percutaneous K-wires fixation, function evaluation was done according to CS score.

Results:The mean follow up CS score was 56.6±10 (35-87) in (group I) and 54.1±9 (18-87) in (group II), values varied depending on the fracture type with worst in 4-part fractures.

Conclusion: We obtained satisfactory results in both groups with each procedure having its advantages and short comings. We found that fixation with percutaneous K-wires presented an efficient treatment option with the advantages of minimal invasions and soft tissue dissection and plate fixation provided stable fixation with minimal implants problems and enabled early range of motion exercise to achieve acceptable functional results.

Keywords:Proximal humeral, PHILOS plate, percutaneous K-wires,3,4 fracture.

1.Introduction:

Proximal humerus fractures are one of the commonest fractures occurring in the skeleton. They account for approximately 4 – 5% of the all fracture. (1) The incidence of fracture of the proximal humerus is bimodal in geriatric due to osteoporosis and in adolescents due to high- energy trauma. A conservative treatment in a sling followed by functional rehabilitation under

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supervision yields satisfactory results in minimally displaced fractures. (2)

Three- and four-part fractures represent 13 to 16% of proximal humeral fractures. However, displaced three-part and four-part fractures need to be reduced and fixation by plate or percutaneous k-wire. (3)

The management of proximal humeral fractures can be challenging because of various destabilizing factors at the fracture site: Numerous muscles attachment and paucity of space for fixing implant and osteoporosis. The treatment is further challenging if there is an intra articular fracture as they carry a high risk of the humeral head necrosis. In Neer’s classification, these are two-part anatomical neck, three-part and four–part fracture and those with dislocation of head of humerus. (4)Neer recommended open reduction and internal fixation for displaced three and four parts fractures.

Most of the proximal humeral fractures are non-displaced or minimally displaced and stable.

These can be treated non-operatively successfully with arm sling and early rehabilitation. (5) but in displaced fracture of proximal humerus Conservative management may be associated with nonunion, malunion, and avascular necrosis resulting in painful dysfunction. (6).

The object of fixation a fracture is to reduce the displacement of each fragment and hold it in place with an implant. Thus, the greater tuberosity fragment, which usually displaces proximally and is rotated upward by the attached rotator cuff muscles, is fixed to the major humeral head fragment. Similarly, the lesser tuberosity fragment displaced by subscapularis is fixed to the humeral head fragment. (7, 8).Specific method of fixation have been proposed for proximal humeral fractures fixation, including plate, screw and wire fastening, and external fixation. (9)

Various methods of osteosynthesis have been suggested for proximal humeral fractures including plate fixation, screw and wire fixation, intramedullary nailing, percutaneous pinning, and external fixation. However, both plate fixation and screw and wire fixation require exposure of the fracture site. In addition, plate fixation is often made difficult by poor bone quality. (10)

Open reduction and internal fixation (ORIF) with plate; has many complications such as long time, blood loss, deep infection due to soft tissue dissection, and insecure fixation due to bad bone quality, screw loosing another complication associated with open reduction and massive fixation is the risk for avascular necrosis of the humeral head because of impairment of the anterior circumflex humeral artery and consecutive devascularization of the fracture fragments, which causes significant functional impairment. (11)

The inherent difficulties with internal fixation have led several studies to recommend hemiarthroplasty for the treatment of three of four-part humerus fractures. However, locked plates allow for more secure fixation in compromised bone, thereby possibly leading to reducedincidence of failure of internal fixation. Newer plates also incorporate suture eyelets

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that further enhance the fixation construct and resist deforming muscular forces. Additional investigation is necessary, but early results with locked plate fixation for the treatment of proximal humerus fractures have been encouraging. (12).

Recent trends are shifting away from open reduction and massive internal fixation (by plates and screws) toward closed reduction and percutaneous fixation as this method is less invasive soft tissue damage and minimal risk of iatrogenic avascular necrosis.(13)

Closed reduction and percutaneous pinning of proximal humerus fractures is a reliable method for fixation in certain patients. Although it is less rigid biomechanically than plate and screw constructs, percutaneous pinning may be used in patients with good bone quality and noncomminuted fracture fragments.

It is essential that an acceptable reduction can be obtained by closed means or open ones. (14) Percutaneous methods of fixation have a major advantage over open reduction and internal

fixation in that there is essentially no soft tissue dissection. (15)We aimed in this study to compare functional outcomes and complications after open reduction and internal fixation of proximal hummers fractures (3 and 4 Neer classification) by plate (PHILOS) versus percutaneous K- wires fixation.

2.Patients and Methods:

This was a prospective study to compare outcome (radiological and functional) between Percutaneous k-wire and Plates Fixation in Proximal Humerus Fractures in adult patients. This sudy was done during period (2020 & 2021).

Patients aged between 15 to 55 years with displaced III part or IV-part proximal humeral fracture according to the Neer classification & AO classification in patientsand who had proximal humerus fracture operated time within 2-7 days were included in the study.

Patient before skeletal maturity, patients with open fractures Gustillo type III &VI and fractures in the same limb to assess perfectly the funnily, associated neurovascular injury. acute infection, pathological fractures and patients with nonunions, malunions or delay in surgery were excluded from the current study.

All patients underwent taking of history, clinical examination, neurovascular examination, radiological examination (Each patient underwent a shoulder trauma series which included antero-posterior (AP), axillary and lateral scapular (Y view) radiographs) and CT was obtained in evaluating articular involvement, degree of fracture displacement and glenoid rim fractures. It was also helpful when axillary view is not obtainable.

All patients will have the preoperative routine lab investigations including complete blood count, random blood glucose level, bleeding profile, liver and kidney function tests.

Ethical declaration of all steps of pre-operative. Operation and post-operative possible complication of the procedure.

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Surgical approach and data collection:

Groupe1 : (plates fixation) Patient position :

The patientswere placed beach-chair position with the affected shoulder resting outside the perimeter of the operating table and small sandbag under the shoulder.

Approach

The fracture was exposed through a delto-pectoral approach in which skin incision from coracoid process to proximal humeral shaft (on the level of axilla) both landmarks can be easily palpated which range from 12-15 cm. we exposed deltopectoral groove with the cephalic vein can be identified by; course of muscle fibers, cephalic vein itself and fat tissue surrounding the vein and then retracted medially or laterally and it should be preserved to reduce the surgical odema of the limb bluntly dissection between deltoid and pectoralis muscle to expose clavipectoral fascia then incision of clavipectoral fascia fracture fragments were reduced. The reduced fracture fragments were held in position with K-wires under guidance of image intensifier.

Most plates have a slotted gliding hole; this should be drilled first in its center to allow for minor adjustments in plate height Definitive fixation with locked plate was done with the plate positioned lateral to the bicipital groove, sparing the tendon of long head of biceps. The plate was placed at least one cm distal to the upper end of greater tubercle. Range of motion of shoulder and impingement were checked on the table.

Group II: (K-wires fixation)

After the arm and shoulder are draped freely, only longitudinal traction force is applied to the upper extremity with the shoulder in adduction to enable fracture reduction. Direct pressure or manipulation over the fracture site is avoided. Special care is taken concerning posterior sagging of the humerus shaft caused by gravity. Confirmation of realignment is undertaken with adjustment of the C-arm of the imageintensifier instead of rotation of the humerus. K- wires are then used as joysticks for adjustment of the reduction. We typically use (4) 2.5-mm nonthreaded- tipped K- wires (also known as pins). We describe the first wire as the reduction pin and the second wire as the antirotation pin and third and fourth as the stabilization pins.

Reduction Pin:

Reduction of head-shaft fragments is performed with K-wires inserted from the anterior, posterior, or lateral side according to the direction of displaced head. These reduction wires are also placed in different positions depending on the fracture angulations in the sagittal plane. The first 2.5-mm non threaded K-wire is placed through the proximal fragment and passed into the shaft of the humerus.

Anti-rotation Pin:

Counter balance to the reduction obtained by the first pin is provided by a second pin parallel to the first one. If the reduction pin is placed anterolaterally, then the anti-rotation pin is placed posterolaterally and vice versa. Both reduction and antirotation pins are advanced to the level of the midshaft.

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Stabilizing Pins

two pins are used to stabilized the fracture side. These pins are inserted into the greater tuberosity drilled into the far medial cortex obliquely passing the fracture line.

Follow up and rehabilitation program

The patient came for clinical follow-up every week during the initial four weeks, then at 6 and 8 weeks postoperatively to monitor fracture healing and detect any possible pin migration or skin problems. If no radiological union had been detected at 6 weeks, another X-ray was obtained at 8 weeks to check for radiological union.

Clinical evaluation:

Every patient was evaluated at the end of the follow up period according to the Constant score (CS), which is a 100-point score system developed by Constant and Murley. (16).This scoring system consists of four variables that are used to assess the function of the shoulder. The right and left shoulders are assessed separately. The subjective variables are pain and activity of daily living (sleep, work,and sport), which yield a total of 35 points. The objective variables are range of motion and strength, which yield a total of 65 points.

Radiological evaluation:

Antero-posterior and lateral radiographs to be taken every 2 weeks for bone healing and union until removal of pins at 6 or 8 weeks then at 3 months ,6 months and 1 year to evaluate reduction, fixation, healing, infection, loosening collapse and osteonecrosis.

Statistical analysis:

Categorical variables will be expressed as Number of patients and percentage of patients and compared across the two groups using Pearson’s Chi Square test (χ2) for Independence of Attributes. Continuous variables will be expressed as Mean ± Standard Deviation and compared across the two groups using unpaired t-test. The statistical software SPSS version 20 had been used for the analysis. An alpha level of 5% has been taken, i.e., if any p value is less than 0.05 it has been considered as significant. Data were collected and submitted to statistical analysis.

3.Results:

The mean age of the patients was 43.8 years with minimum age patient of 19 year and maximum of 55 year. The male:female ratio was 1.9:1.1 with male predominance. Right upper extremity was involved more commonly with the ratio being 1.7:1.3. The predominant mode of injury was due to road traffic accident (70%) followed by fall (30%). The majority of fractures in the present study were Neer’s type 3 part (66.6%), followed by 4 part (33.3%). (Table 1)

In our study, in (Group I) mean operative time was 95 minutes (range from 70 to 120 min.) and average blood loss was 500 ml. (range from 300 to 700 ml.) (Table 2).

Intra-operative imaging timing in (Group I) ranged from 1 to 2 minutes while in (Group II) ranged from 4 to 6 minutes (Fig 1).

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Table(1):Socio-demographic characteristicsofstudygroups

Variable No. %

Gender Male 19 63.33%

Female 11 36.66%

Chronicillness Non 15 50.0%

DM 5 16.66%

HTN 5 16.66%

CRF 3 10.0%

B.asthma 2 6.66%

Typeofwork Overhead 9 30.0%

Otherwork 21 70.0%

Table (2): Differences in operative data according to study groups

Variable plate Percutaneo Test P- Si

andscrew sk-wire valu val g.

s e ue

No.=15 No.=15

Interval Mean±SD 2.80±1.23 2.10±1.20 1.5• 0.1 NS

betweentrauma&in Range 1–4 1–5 2

terventionindays

Amountofbloodlossin Median(IQR) 325(250- 30(20-40) 32.3 0.0 HS

cm 400) ǂ 01

Range 250 –600 20–50

Timeofsurgeryinh Mean±SD 1.72±0.30 1.09±0.46 4.4• 0.0 HS

ours Range 1.3–2 0.45–1.5 01

TimeofIOPimage Mean±SD 1.30±0.54 4.70±1.42 8.6• 0.0 HS

inminute Range 0.5–2 2–6 00

Neer'sclassification Three 9(60.0%) 8(53.3%) 1.2* 0.2 NS

partfract 7

ure

Four 6(40.0%) 7(46.6%) partfract

ure

Length ofskin Lessthan2c * 0.0 HS

incision(cm) 14.26 m 01

±2.23

1.8 1.6

1.4 1.72

1.2

1.0 1.09

0.8

lockedplate and Percutaneous screws pinning

Timeofsurgeryin hours

Fig (1):Comparisonbetween(groupI)and(group II)regardingtimeofsurgery

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TimeofIOPimageinminute

4.70 5.0

4.0

3.0

1.30 2.0

1.0

0.0

lockedplate andscrews Percutaneouspinning

Fig (2): Comparison between group 1 and group 2 regarding time of IOP image.

Union time was shorter in plate group but not significantly as it was distributed as 13.26±3.97 and 14.64±3.99 respectively (Fig 3).

distributed as 13.26±3.97 and 14.64±3.99 respectively.

uniontime

15 14.5 14

13.5

plate k-wire

Fig(3): diagram of union time.

Table: (3)DifferencesinCSscoreaccordingtostudygroups.

Constantscore Plategroup (15) k-wiregroup Testv p- sig

(15) alue value

pain 11.1±4(5-15) 10.9±4(5-15) 0.13 0.88 NS

Range 30(20-40) 29(18-40) 0.36 0.71 NS

of motion

Power 15(5-25) 15(5-25) 0.91 0.35 NS

Activities 14(8-20) 15(10-20) 0.9 0.35 NS

of dailyliving

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Total 70.4(38-100) 69.9(37-100) 0.63 0.53 NS

Inourstudythere wasnosgnificantdifferencebetweentwogroupsinCSscore (Table 3) and no significant difference between two groups regarding range of motion (table 4)

Table(4):meanrangeofmotion forbothgroup

Direction Plategroup (15) k-wiregroup (15) Testv P sig alue value Flexion 130±50(160-180) 125±43(55-175) 0.28 0.77 NS Abduction 135±50(60-180) 122± 43(50-170) 0.8 0.42 NS

Internal 6(0-10) 6(0-10) 0.0 1.0 NS

rotation

External 5(0-10) 5(0-10) 0.0 1.0 NS

rotation

Post-operative follow up results according to constant scoring system, after 3 and 6 months.

After 3 months 5 patients had excellent result in (Group I) and 3 patients in (Group II) while good results were achieved in 3 patients in (Group I) and 6 patients in (Group II) and poor results in 7 Patients in (Group I) and 6 in (Group II).

After 6 months, excellent result was achieved in 7 patients in (Group I) and 8 patients in (Group II), while good results in 5 patients in (Group I) and 5 patients in (Group II), Poor results in 3 patients in (Group I) while 2 patients in (Group II) (Table 5).

Table(5):Relationbetweenconstantscoreandstudygroups

Result plateandscrews Percutaneous Testva P- Sig ue* val .

k-wire ue

No. % No. %

3m Excellent 5 33.33% 3 20.0% 1.5 0.4 NS

5

Good 3 20.0% 6 40.0%

Poor 7 46.66% 6 40.0%

6m Excellent 7 46.6% 8 53.33% 0.2 0.8 NS

7 7

Good 5 33.33% 5 33.33%

Poor 3 20% 2 13.33%

Chi-squaretest 2.43 4.36

4.Discussion:

Proximal humerus fracture is the most common fracture of the shoulder. It is the second most common site of fracture in the upper limb after distal radius. These fractures have been treated with a wide range of options, namely non operative, ORIF, percutaneous screw/pin fixation, hemiarthroplasty and external fixation. Fractures of this region are common both with high- energy injuries in people of all ages, as well as with simple falls in older people with osteoporosis. In elderly patients fragility of the bone complicates the pattern of fracture. (17) In our study the mean age of the patients was 43.8 years with minimum age patient of 19 year and maximum of 55 year. The male:female ratio was 1.9:1.1 with male predominance. Right

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upper extremity was involved more commonly with the ratio being 1.7:1.3. The predominant mode of injury was due to road traffic accident (70%) followed by fall (30%). The majority of fractures in the present study were Neer’s type 3 part (66.6%), followed by 4 part (33.3%), compare toMayank V et al. (18) The mean age of the patients in the present study was 46 years with minimum age patient of 22 year and maximum of 68 year.

The male: female ratio was 1.36:1 with male predominance. Right upper extremity was involved more commonly with the ratio being 1.16:1 which was due to right handedness of the majority of the population. The predominant mode of injury was due to fall (53.8%) followed by road traffic accident (46.2%). The majority of fractures in the present study were Neer’s type 3 part (65.3%), followed by 4 part (34.7%).

In our study, In (Group I) mean operative time was 95 minutes (range from 70 to 120 min.) and average blood loss was 500 ml. (range from 300 to 700 ml.) less than that of Jura et al. (19) stated that mean operation time was 100 minutes (range 80-120 minutes) and the average blood loss during surgery was 600 ml (range 400-1000 ml) while In (Group II) mean operative time was 40 minutes (range from 30 to 50 min.) and average blood loss was 30ml.(range from 30 to 40 ml) compared to that of Jura et al. (19) 50 minutes (range 35-70 minutes) and blood loss was 100 ml (range70-160ml).

Intra-operative imaging timing in (Group I) ranged from 1 to 2 minutes while in (Group II) ranged from 4 to 6 minutes the same of Younes A et al (20) Intra-operative imaging timing in (Group I) ranged from 1 to 2 minutes while in (Group II) ranged from 4 to 6 minutes.

In our study all patients showed radiographic union by 12 weeks except one patient non union in (group II) compare to Seyhan et al. (21) All patients showed radiographic union by 12 weeks postoperatively in both groups and Jaberg et al. (22) encountered nonunion in 4% of patients following closed reduction and percutaneous K-wire fixation of unstable proximal humeral fractures.

In our study the average constant score was 70.4 in (group I)) compare to that of Frankhauseret al. (23) The average constant score was 74.6 and to Emanuel V.et al (24) the mean Constant- Murley score was 57.9±21.7 while in (group II) the average constant score was 69.9 compared to Kumar A et al (25) 80.8 score in (percutaneous k-wire)

In (group I) of our study, the result was excellent in seven patients (46.6%), good in five patients (33.3%) and poor in three (20%) according to constant score system compare to that of Atilla A et al. (26) The results were excellent in thirteen patients (40.6%), good in nine patients (28.1%), fair in eight patients (25%), and poor in two patients (6.3%). In (group II) of our study, eight patients (53.3%) had an excellent, five patients (33.3%) had good, and two patients (13%) had poor result according to constant score compare to that of Shiva et al. (27) (10 %) had excellent functional outcome, (55 %) had good functional outcome, (20 %) had moderate and (15 %) had poor results.

In our study, there were no major complications intraoperative in both groups. Postoperative complications were noted in 7 patients in (group1) and 7 patients in (group II).

In (group I) of our study two patient had avascular necrosis (13.3%), two patient had infection (13.3%), delayed union (6.6%) and the last two patient had decrease range of motion(13.3%).compare to that of Jura et al. (19) Two had avascular necrosis, two patients had non-union, four patients had infection and. while In group (II) three patient had pin tract infection (20%), one patient had delayed union (6.6%), one patient had non union(6.6%), the last two patient had pin loosening (13.3%) compare that of Baldev et al (28) Out of all these patients four patients had pin site infection, four patients had mal-union, one patient had non-union and no patients had avascular necrosis of the humeral head.

Magovern and Kenner (29) found good constant score with surgery and relatively few

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Annals of R.S.C.B., ISSN:1583-6258, Vol. 25, Issue 6, 2021, Pages. 13601 – 13612 Received 10 March 2021; Accepted 22 March 2021..

complications with better functional outcome for percutaneous fixation.

Massimo et al. (30) found that percutaneous fixation treatment may represent reasonable treatments for proximal humerus fractures in elderly patients affected by severe comorbidities contraindicating an open surgery specially in case of significative critical health conditions.

In a study conducted by Massimo et al. (30) it was seen that PHILOS plate fixation provided more anatomical reduction with minimal implant problems and enabled early range of motion exercises to achieve acceptable functional results.

5.Conclusion:

We obtained satisfactory results in both groups with each procedure having its advantages and short comings. We found that fixation with percutaneous K-wires presented an efficient treatment option with the advantages of minimal invasions and soft tissue dissection and plate fixation provided stable fixation with minimal implants problems and enabled early range of motion exercise to achieve acceptable functional results.

6.Conflict of Interest :

Noconflictofinterest.

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