Analysis of Functional Outcome of Proximal Humerus Fractures Treated with Locking Compression

SYNOPSIS

OF

DESSITATION TOPIC

“ANALYSIS OF FUNCTIONAL OUTCOME OF PROXIMAL HUMERUS FRACTURES TREATED WITH LOCKING COMPRESSION PLATE”

BY

DR. CHETAN JOHN RASQUINHA

GUIDE-DR. MURLIDHAR N.

HOD -DEPARTMENT OF ORTHOPAEDICS

VYDEHI INSTITUTE OF MEDICAL SCIENCES

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR SYNOPSIS

6. Brief resume of the intended work

6.1Need for study : Modalities of treatment available for proximal humerus fractures are

Medical- immobilization may be achieved with a sling, shoulder immobilizer, or a sling with an accompanying swathe. These devices provide varying degrees of constraint . Conservative treatment of proximal humerus fractures in patients older than 75 years provides good pain relief with limited functional outcome.

Surgical- Surgical management of proximal humerus fractures by method of fixation (eg, closed reduction with no fixation, percutaneous fixation, open reduction with internal fixation, humeral head replacement associated with tuberosity fixation.

The advent of locking compression plate technology ( LCP) offers an innovation beyond conventional compression plating in the fixation of osteoporotic bone: the plate acts as a fixed-angled construct and converts shear stress to compressive force. Locking plates function as "internal fixators" with multiple anchor points. . The strain theory demonstrates that anatomic reduction is not required for bone healing, and that tolerable strain (2%-10%) can promote secondary bone healing

Advantages Of LCP.

1)Anatomic Reduction: Locked plate design allows lag screw and compression plating technique

2) Stable Internal Fixation: Locking screws increase stability in osteoporotic and metaphyseal bone

3) Preservation of Blood Supply- Limited bony contact stabilizes fracture without plate-to-bone compression Tapered tip allows submuscular plate insertion, decreasing tissue destruction 4) Early Active Pain Free Mobilization Multi directional stability

A more stable construct = earlier return to ADL

5)No periosteal stripping required

6)Minimal invasive approach

There are limited studies on LCP, hence we would like to undertake the study to evaluate the functional outcome of patient with complex Proximal humeral fractures (One part to Four part) fixed with locking compression plate. To evaluate the biomechanics of the upper limb post surgery and advantages of LockingComperssion Plate ( LCP.)

6.2 Review of Literature :

AClinical trial by Fankhauser F et al say - Their data show that using the Locking Proximal Humerus Plate for treatment of all types is a reliable procedure, with good results being obtained with careful planning and familiarity with the special features of the operative technique.” 1

A cadaveric study by Robert J. Gillespie et al says - Proximal humerus fractures trail behind only femoral neck and distal radius as the third most common fracture in patients older than 65 years.Locking-plate constructs exhibited significantly less loosening than blade-plate constructs for torsional loading in cadavericspecimens. For simulated humeral neck fractures subjected to cyclic loading, locking-plate constructs demonstrated significantly greater torsional stability and similar bending stability to blade plates in a cadaveric specimen model. These results indicate potential advantages for locking-plate fixation. 2

A study by Darin M. et al says- In their opinion the majority of 3- and 4-part proximal humerus fractures in elderly patients with osteoporosis can be treated successfully with proximal humeral locking plates, yielding a more functional shoulder, as long as care is paid to achieving an anatomic reduction and tuberosity fixation as elucidated in recent literature. Hemiarthroplasty may serve as a salvage procedure should ORIF fail, or in the situation where acceptable reduction is not obtainable or maintainable 3

A study by Brandon S Shulman et al - suggest that treating proximal humerus fractures operatively with locked plates can overcome the challenges of poor bone quality that often occurs with increasing age .4

A study of the role of locking technology in the upper extremity bySiddharth B. Joglekar⋅Asif M. Ilyas - showed standard non locking plates are used, tightening of the screw leads to compression of the plate against thebony surface. The friction between the plate and the boneprovides stability to the construct. The screw heads arefree to toggle in the plate holes and hence bicortical purchaseis needed to prevent loss of stability The disadvantage of this system is that the periosteal blood supplyalong the undersurface of the plate is lost. Locked plates act as fixed angle devices by allowing the screwheads to lock into the plate holes. Thus they can functionas internally applied external fixators which do not haveto rely on the friction at the plate bone interface for stability.5

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6.3Objectives of the study

• To evaluate the functional outcome on using LCP.
• To evaluate the complications.

1. Materials and methods:

7.1 Source of data: Cases admitted atVydehi hospital and other tertiary health care centres

7.2 A. Method of collection of data (including sampling procedure, if any)Patients coming to Emergency department and Orthopedic OPD’s
B. Study design- Observational and prospective Study and interview

C. Study period- 3year.

D. Place of study-VIMS & RC Bangalore & other tertiary health care centers

Methodology and type of data collected– Patients fulfilling the following inclusion criteria will be included. They will be followed up for a period of 3 months, 6 months, and 1 year post operatively to determine (a) functional outcome and advantages of LCP (b)complications

Inclusion criteria

Age group between 20 ( years after physial closure)to 80years

Neer’s classification type 1 to type 4 that includes 1 part to 4 part
fractures of shaft of humerus

Compound injuries grades 1,2 and 3a and 3b according to AO Classification.

Previously failed procedure of proximal humerus fixed by tension Band Wiring or treated by non compression plates

Subjects who were treated conservatively and have complication like non union or malunion ofproximal humeral shaft and now being treated with LCP.

Exclusion Criteria

Severe crush injury to upper arm

Brachial Plexus Injury

Patients below 20 years of age where physial closure has not been attained

Compound Grade 3 c Fractures according to AO Classification.

E. Statistical methods involved- To follow up the cases and do statistical study according to Neer’sclassification. Compare the cases usingthe constant score.Descriptive statistics will be used and statistical test of proportion will be used. Kruskal Wallis Test- to compare all the follow up cases based on constant score.

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.

It will requireCT scan followup post operatively for some patients

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

yes

List of References

Authors

TEXT BOOK OF OPERATIVE ORTHOPAEDICS BY CAMPBELL 13th EDITION VOLUME 3, PART 15.

TEXT BOOK OF TRAUMA BY ROCKWOOD& GREEN 7TH EDITION, VOLUME 1, SECTION 2, CHAPTER34.

Reference 1- clinical orthopaedics and related research [2005(430) 176-181] a clinical trial, journal article.on A new locking plate for unstable fractures of the proximal humerus.- By Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. DEPARTMENT OF TRAUMATOLOGY, UNIVERSITY MEDICAL CENTER, GRAZ, AUSTRIA.

Reference 2 – Bio Mechanical Evaluation of three part Proximal Humerus fractures – a cadaveric Study. By Robert J. Gillespie MD , Vimala Ramachandran MD , Ethan S , Lea MD , Heather A , Vallier MD.

Reference 3 –Healioorthopedics journal treatment of complex proximal humerus Fractures a comparison with other Fixations studies – By Darin M , Friess MD , Albert Attia MD, Hather A , Vallier MD. Journal edition Dec 2008 Vol 31 Issue 12.

Reference 4-Outcomes After Fixation of Proximal Humerus (OTA Type 11) Fractures in the Elderly Patients Using Modern Techniques

Brandon S. Shulman,1Crispin C. Ong,1James H. Lee,1Raj Karia,1Joseph D. Zuckerman,1 and Kenneth A. Egol

Reference 5-Siddharth B. Joglekar⋅Asif M. Ilyas

Received: 26 April 2009 / Accepted: 6 July 2009

2009 Jun;91(6):1320-8. doi: 10.2106/JBJS.H.00006

Proximalhumerusfracture: AO Classification
Müller M, In: Manual of internal fixation, 118-125, 1988
A: Extra-articular unifocalfracture
A1 Extra-articular unifocal tuberosityfracture
.1 Gr Tuberosity, not displaced
.2 Gr Tuberosity, displaced
.3 associated with GHdislocation
A2 Extra-articular unifocal impacted metaphysealfracture
.1 no frontal displacement
.2 varusmalalignment
.3 valgus malalignment
A3 Extra-articular unifocal non-impacted metaphysealfracture
.1 simple, angulated
.2 simple, translated
.3 multifragmentary

B: Extra-articular bifocalfracture
B1 Extra-articular bifocalfracturewith metaphyseal impaction
.1 Lateral and Gr tuberosity
.2Medialand lesser tuberosity
.3Posteriorand Gr tuberosity
B2 Extra-articular bifocalfracturewithout metaphyseal impaction
.1 without rotational displacement
.2 with rotational displacement
.3 multifragmetaphyseal with one of the tuberosities involve
B3 Extra-articular bifocalfracturewith GHdislocation
.1 Vertical cervical line, Gr Tuberosity intact, Ant-meddislocation
.2 Vertical cervical line, Gr Tuberosityfracture, Ant-meddislocation
.3 Lesser tuberosityfracture,posteriordislocation

C: Articularfracture
C1 Slightly displaced
.1 cephalotubercular, valgus alignment
.2 cephalotubercular, varus alignment
.3 anatomical neck
C2 Impacted and significantly displaced
.1 cephalotubercular, valgus alignment
.2 cephalotubercular, varus alignment
.3 Transcephalic and tubercular, varus alignment
C3 Dislocated
.1 anatomical neck
.2 anatomical neck and tuberosities
.3 cephalotubercular fragments

Proximalhumerusfracture: Neer’s Classification
Neer II,CS, JBJS (A), 52: 1077-1089, 1970
Minimally displaced one partfractures
No segment displaced > 1cm or angulated > 45 deg
Two partfractureof anatomical neck, articular segment displaced
High risk of AVN
Two partfractureof the surgical neck with shaft displacement:
-Impacted- >45 deg angulation, apexanterior
-Unimpacted- shaft dispalcedantero-med, head neutral
-Comminuted- fragmented upper shaft
Two part greater tuberosity displacement
Two part lesser tuberosity displacement
Three part displacements: one tuberosity remains attached to the head
Greater tuberosity displacement
Lesser tuberosity displacement
Four partfractures,fracturedislocationand head splittingfractures:
articular segment displaced out of contact with glenoid, no soft tissue attachment, no tuberosity contact

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