Philosplating: Emerged Techniques in Surgical Management
1Binod ChandraRoul, 1Pullin Bihari Das, 2Jatindra Nath Mohanty*
1Department of Orthopaedics, IMS and Sum hospital, SOA deemed to be University, Bhubaneswar-751003, Odisha, India
2Medical Research Laboratory, IMS and Sum hospital, SOA deemed to be University, Bhubaneswar-751003, Odisha, India
Dr. Jatindra Nath Mohanty, Assistant Professor, Medical Research Laboratory, IMS and Sum hospital, SOA deemed to be University, Bhubaneswar-751003, Odisha, India
Mail [email protected]
Safe fixation of displaced proximal fracture of the humerus is a challenging problem. A total of 32 patients with acute three- or four-part displace fractures of the proximal humerus were treated with open reduction and internal fixation using the proximal humerus internal locking system (PHILOS). There were 23 women and nine men, with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the results were assessed based on consistent results. The mean follow-up time was 11 months (3 to 24). In 31 patients (97%) the fractures were combined clinically and radiologically for a mean of 10 weeks (8 to 24). Consistent mean score on recent exams was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients over 60 years of age (18 patients) with patients under 60 years of age (14 patients) (t- test, p = 0.8443). There was one case of parental union, abuse, and fracture.PHILOS provides stable fixation in proximal humerus fractures. To prevent potential complications like avascular necrosis, meticulous surgical dissection to preserve vascularity of humeral head is necessary.
Key words:proximal humerus, Surgical management, PHILOS, fixation
Philos plating provide an alternative fixation method for fractures of the proximal humerus. This provides stable fixation in young patients with good bone quality, sufficient for early mobilization. Failure of screws to maintain fixation in the elderly remains a problem.The incidence of fractures of the proximal humerus is between 4% and 5% of all fractures. They occur most frequently in the elderly. In younger patients, the cause is high-energy trauma and the displacement is often more severe. These patients usually have dislocated fractures . Most of these fractures, both in younger and older patients, are stable and minimally displaced and can be managed conservatively . However, unstable displacement fractures are very common in the elderly. .
Safe fixation of displaced three- and four-part fractures of the proximal humerus remains a problem [4-6]. A variety of methods have been described, including Kirschner (K) cable, external fixation, tension band fixation, Rush pin, intramedular nail, and lining. 8 Plates The
humeral internal locking system (PHILOS) (Synthes, Stratec Medical Ltd., Mezzovico, Switzerland) is intended to improve screw fixation in osteoporotic bone and minimize soft tissue dissection. It combines the principle of fastening with conventional plates with that of the locking screw. The screw holes in the shaft can accept standard screws and adjust screws. The plate is preformed and shaped for the proximal humerus. No plate compression is required, reduces the risk of reduction losses and maintains blood supply to the bone. Locking screws in the plate provides angular and axial stability and reduces the risk of reduction losses. The locked interface also provides solid stability preventing surface subsidence in the metaphysical area.This prospective study was conducted to evaluate the effectiveness of the PHILOS plate in treating displaced fractures of three and four parts of the proximal humerus.
Patients and Methods
A total of 32 patients with displaced fractures in three and four parts of the proximal humerus underwent open reduction with internal fixation using the PHILOS plate. There were nine men and 23 women with a mean age of 59.9 years (18 to 87). A total of 18 patients were older and 14 younger than 60 years. 23 patients were injured from simple falls, six were in car accidents and three fell from stairs. Twenty patients had three and 12 four-part fractures.
The operation was performed in all cases by a consultant surgeon (NA or MH) under general anesthesia with the patient in the "beach chair" position. A deltopectoral approach with minimal soft tissue dissection was used. The bicep tendon is identified and withdrawn, and a fracture is seen between the bulb and behind the bipital groove. When the larger tubers are moved backwards, efforts are made to reduce them anatomically. Stretching the arm reduces tension at the fracture site. Rest is reduced and temporarily held with K-ladders. The reduction is examined fluoroscopically and a PHILOS plate with at least four proximal fixing screws is then applied.
Allomatrix bone replacement (Wright Medical, Arlington, Tennessee) was used in two patients with poor bone care. AO cortex screws were used to secure the plate to the shoulder shaft in 29 patients. However, locking screws were used in three patients with severe osteoporosis.
The wound is closed via an inlet tube which is removed after 24 hours. The arm is held in a sling post surgery. The pendulum movement starts from the first postoperative day and the shoulders are moved with active assisted exercises, followed by active exercises for three weeks.
All patients were followed at two and six weeks and at three month intervals until reunification was achieved. Assessment of shoulder function is based on consistent results.10 Radiographs show callus formation and cortical continuity as evidence of radiographic transition. Functional outcome in patients over 60 years of age compared with younger patients. The mean follow-up time was 11 months (3 to 24). X-rays were examined retrospectively at the end of the study.
Student's t-test with 95% confidence intervals (CI) was used to compare groups and statistical significance was set at p = 0.05.
No patient was lost to follow-up. A total of 31 fractures (97%) were combined clinically and radiologically. Average reunion time was 10 weeks (8 to 24). Consistent mean score at the last review was 66.5 (30 to 92). The relationship between outcome and age is shown in table 1. A total of 27 patients (84%) had very good or satisfactory results, but five (16%) had poor results.
The mean score in patients over 60 years was 66.1 (30 to 81) and in patients under 60 years 67.1 (38 to 92). This difference was not statistically significant (t-test, p = 0.8443).
Table I. Age-related Constant scores10
Number of patients (%)
Constant score Age < 60 yrs
> 75 (excellent) 6 (43) 9 (50)
50 to 75
6 (43) 6 (33)
< 50 (poor) 2 (14) 3 (17) Table 2.Implant-related complications
Patient Age (yrs)
Type of fracture
1 68 3-part Nonunion and avascular
necrosis Transient axillary nerve palsy
2 82 3-part Broken distal screw No further
treatment 3 87 4-part Malunionduetolossofpurchaseinth
4 47 4-part Malunion No further
5 40 3-part Impingement Plate removed
6 72 3-part Prominent proximal screws Removal of screws 7 67 4-part Prominent proximal screws Removal of screws
The complications are summarized in Table 2. There was a superficial wound infection that was treated with oral antibiotics and one patient had temporary paralysis of the axillary nerve. Three patients (9%) had stroke symptoms in which the plate had to be removed in one and the screw protruded in half. There was abuse in two patients (6%); both had four-part fractures and poor results. In one case, the distal screw (3%) broke when the plate was separated from the bone.
However, fracture orientation remained satisfactory and no further treatment was required. One patient (3%) had avascular dislocation and necrosis of the humeral head. Both complications occurred in a 68-year-old woman who had a partial fracture of the proximal humerus due to low energy injury. The plates are secured with nine sets of screws on the head and bicortical self- tapping screws on the shaft. Postoperative radiographs show good reduction with all proximal locking screws in the humeral head. After six weeks, X-rays showed loss of fixation, collapse of the head of the shoulder and penetration of the proximal locking screw into the articular surface of the head of the shoulder. These screws are removed every day. The fracture collapses into varus. A hemi-arthroplasty was then performed five months after the PHILOS plate was placed.
This study shows that treatment with the PHILOS plate can provide satisfactory results in patients with displaced fractures of three and four parts of the proximal humerus. The fixation is usually stable enough to allow early mobilization.
Tape wiring is the most common method of repairing these fractures. However, several studies have shown no difference in functional outcomes between patients treated with plaster cables and those treated without surgery.
AO-T plate (AO-ASIF, Davos, Switzerland) and cloverleaf performed poorly in patients with insufficient bone marrow and had a rate of complications including screw loosening, subacromial stroke, and avascular necrosis of about 40% .5,8 Four-part refugees Fractures in the elderly can be treated with hemiarthroplasty. Pain relief is good, but function and range of motion are less predictable [6,12]. There is some evidence that the results may not depend on the design of the prosthesis.13 Good results have been reported after using inverted shoulder arthroplasty.
Polarus nails (Acumed Inc., Beaverton, Oregon) have been used to treat these fractures This gives good results, but the choice of site of entry can be difficult and lead to fragmentation of the lateral metaphysis. This nail was used in 80% of patients by Rajasekhar et al.[15,16].
A Plan Tan humerus fixation plate (Plan Tan Medizin-tecknik GmbH, Lambrechtshagen, Germany) can also be used, but Sadowski et al.  reported 100% rejection in elderly patients.
Penetration of the proximal screw through the head during impact is a major complication.
There are only two studies in the British literature describing the use of the PHILOS plate.
Bjorkenheim et al.  described a study of 72 patients using these plates: after six months, follow-up showed a consistent mean score of 72. They specifically recommended the use of plates to treat fractures of the proximal humerus in patients with poor bone quality. They
reported two cases (3%) non-association, three cases (4%) avascular necrosis, and two failed implants (3%) with loss of fixation.
Koukakis et al.  published a series of 20 patients with two, three and four part fractures treated with this plate. Constant's mean score at six months was 76. They described two complications; one adult with the plate detached from the shoulder shaft, and the other patient with symptoms of a prominent metallic structure. There was no difference in functional outcome between younger (<65 years) and older (> 65 years) patients. The authors stress the importance of anatomical fracture reduction and correct surgical technique.
In our study, all fractures were combined with the exception of one patient (3%) who had avascular obstruction and necrosis of the humeral head. One patient had to remove the plate and two patients had to remove the screws. The consistent mean score in this study was 66.5.
Although this is lower than the other series [19,20], we only included three and four fracture sections.
PHILOS plates can be of very rigid construction if locking screws are used proximally and distally. This can cause concentration of tension in the surgical neck of the humerus. This can be reduced by using standard screws on the shoulder shaft, thereby reducing structural rigidity. For osteoporotic bones, multiple cortical self-tapping locking screws should be used to increase the screw working length and avoid potential bone-thread interface problems. Increasing the distance between the plate and bone can also decrease the stability of the structure
Although small, our study shows that the PHILOS plate can provide good results in the treatment of three- and four-part displaced fractures. If the bone supply is poor, we recommend filling the head and shaft of the humerus with a bone graft or bone replacement.
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