Comparative study of ORIF with philos plate vs CRIF with k wiring of Neers 2part and 3part proximal humerus fractures

Comparative study of ORIF with philos plate vs CRIF with k wiring of Neers 2part and 3part proximal humerus fractures.

1. A COMPARATIVE STUDY OF ORIF WITH PHILOS PLATE Vs CRIF WITH PERCUTANEOUS K WIRING OF NEER’S 2-PART AND 3-PART PROXIMAL HUMERUS FRACTURES MODERATOR DR.SUNDRESH K BY, DR BALAGANGADHAR JUNIOR RESIDENT

2. INTRODUC TION Proximal humeral fractures, defined as fractures occurring at or proximal to the surgical neck of the humerus . nowadays proximal humeral fractures account for almost 7% of all fractures. 80% of all Humeral fractures. Patients >65Yrs- Second most common fracture of the upper Extremity F:M-3: 1

3. PATHOANATOMY The region of transition between the articular cartilage and surrounding bone is defined as the anatomic neck whereas the region immediately inferior to the tuberosities is termed the surgical neck Articular Segment is almost spherical, with a diameter of curvature averaging 46 mm (Ranging from 37 to 57 mm ) Inclination of the humeral head relative to the Shaft averages 130°(centrum collum diaphyseal angle[CCD] Retroversion of the head varies from 18 to 40 °

4. Greater tuberosity has three regions into which the Supraspinatus, infraspinatus and teres minor inserts. Subscapularis tendon -inserts on lesser tuberosity ,which is Separated from greater tuberosity by the bicipital Groove. Muscle insertion on these 4 segments and the magnitude and direction of the forces Causing injury, determine the pattern of fracture lines, displacement and angulation

5. BLOOD SUPPLY The ascending branch of the anterior circumflex humeral artery has been considered to provide most of the blood flow to the articular segment. Several studies have shown branches from PCHA to the posteromedial head to be equally important Arcuate artery of Liang -supplies Humeral head If the medial calcar of the humerus is spared by the fracture,the vessel is spared .

6. MECHANISM OF INJURY In individuals 60 years or older , over 90% of proximal humeral fractures result from a fall from a standing height . In younger individuals there is a higher incidence of proximal humeral fractures occurring outside the home, as a result of higher-energy trauma , such as a fall from a height, motor vehicle accidents (MVAs), sports, or assaults. The proximal humerus can fracture as a consequence of three main loading modes : Compressive loading of the glenoid onto the humeral head, Bending forces at the surgical neck, Tension forces of the rotator cuff at the greater and lesser tuberosities

7. DEFORMING FORCES The greater tuberosity is pulled posteromedially by the effect of the Supra-and infraspinatus tendons . The lesser tuberosity is pulled anteriorly by the subscapularis The shaft segment is pulled anteromedially by the pectoralis major tendon

8. X-RAY VIEWS

9. CT Scan -Allows more detailed understanding of fracture configuration , degree of osteopenia , presence and location of bone impaction and extent of fracture comminution

10. CLASSIFICATION OF PROXIMAL HUMERUS FRACTURES In 1934, Codman described proximal humerus fractures as occurring along the lines of epiphyseal scars and observed four possible fracture fragments : The articular surface The humeral shaft The greater tuberosity The lesser tuberosity

11. Neer classification In 1970, Neer introduced the concept of fracture segments instead of fragments. proximal humeral fractures can reproducibly yield up to four anatomic segments with or without additional fracture lines , rather than a single fragment. Displaced fractures were arbitrarily defined as those in which a segmen t was translated by at least 1 cm or angulated by a minimum of 45 degrees . Fractures of less than 1 cm of displacment and less than 45 degrees of angulation are considered nondisplaced and are commonly called one-part fractures .

12. AO/OTA Classification The AO/OTA classification is based on fracture location and the presence of impaction , angulation , translation , or comminution of the fracture , as well as whether a dislocation is present. These fractures are classified as belonging to the 11 bone segment (1 for humerus , 1 for proximal segment) and they are sub classified into types, groups, and subgroups. Finally each subgroup fracture is assigned a level of severity. Type A fractures are extra-articular unifocal fractures associated with a single fracture line , type B are extra-articular bifocal fractures associated with two fracture lines , type C are articular fractures which involve the humeral head or anatomic neck .

13. Non-operative treatment of proximal humeral fractures The majority of proximal humeral fractures are non displaced or minimally displaced and nonoperative treatment is indicated Radiographically,stable fractures exibit impaction or interdigitation between bone fragments Clinically , fracture stability may be assessed by palpating the proximal humerus just distal to the acromion with one hand ,while rotating the arm at the elbow with the other .if the proximal humerus is felt to move as a unit with the distal segment ,the fracture is considered stable.

14. NON OPERATIVE TREATMENT Indications Stable non-displaced or minimally displaced fractures Patients not fit for surgery Elderly patients with low functional demand Relative contraindications Displaced fractures with loss of bony contact Closed followup is required to confirm acceptable alignment and fracture stability. Weekly radiographs should be performed during the first month of treatment ,followed by biweekly radiographs until 6 weeks after injury or initial callus formartion is visible.

15. COMPLICATIONS FOLLOWING NON-OP TREATMENT Avascular necrosis Nonunion Malunion Stiffness Rotator-cuff dysfunction Post-traumatic arthritis

16. OPERATIVE TREATMENT OF PROXIMAL HUMERUS FRACTURES Many surgical techniques have been described ,but no single approach is considered to be the standard of care Appropriate treatment is individualized and selected on the basis of the fracture pattern and the underlying quality of the bone Surgical options Open reduction and internal fixation Tension band fixation Closed reduction and percutaneous fixation Intramedullary nailing Hemiarthroplasty Reverse total shoulder arthroplasty

17. Complications The most frequently reported complications after proximal humeral fractures following operative intervention are; Nonunion Malunion Implant failure Humeral head collapse and AVN Infection Post-traumatic arthritis Hardware penetration Axillary nerve dysfunction Revision surgery, and mortality

18. A Comparative Study of Open Reduction and Internal Fixation with PHILOS Plate versus Closed Reduction and Fixation with Percutaneous K Wiring of Neer’s 2-Part and 3-Part Proximal Humerus Fractures

19. INTRODUCTION We wanted to assess the clinical, functional, and radiological outcomes of two surgical treatment methods (K-wire application and PHILOS plate fixation) for proximal humerus fractures. A randomised prospective study of 40 cases was conducted in Sapthagiri Institute of Medical Sciences and Hospital from April 2017 to June 2018. Group A underwent ORIF with PHILOS Plate . Group B underwent CRIF with percutaneous K wiring . Patients were evaluated clinically by Constant - Murley Score . Radiologically x rays were taken to evaluate the progress of union.

20. METHODS Inclusion Criteria Two part, three part proximal humeral fractures. Acute fracture. Age from 25 to 60 years. Exclusion Criteria Associated humerus shaft fracture. Associated neurovascular injury. Acute infection. Pathological fractures. Old fractures. Compound fracture.

21. Conservative treatment of displaced two and three part fractures can result in non-union or mal-union and give rise to poor functional results. Open reduction (OR) with internal fixation (IF) is a good method for fine reduction , but extensive soft tissue exposure during Open Reduction impairs the vasculature and doubles the risk of humeral head avascular necrosis (AVN). Closed reduction (CR) and IF with Kirschner wires (K - wires) is another method for the treatment of proximal humeral fractures. CR with percutaneous fixation preserves the soft tissues and prevents further soft tissue damage .

22. Surgical Techniques OPEN REDUCTION INTERNAL FIXATION WITH PHILOS PLATING CLOSED REDUCTION AND PERCUTANEOUS FIXATION USING K-WIRES

23. Open reduction and internal fixation with PHILOS plating ORIF is the most frequently used method of surgical treatment of proximal humeral fractures Surgical approaches Deltopectoral approach a 12-14 cm long skin incision between the coracoid process and the proximal humeral shaft. The shape of the skin incision can be straight or curved depending on surgeon’s preference

24. Deltoid-splitting approach This incision is placed between the acromial part (2) and the spinal part (3) of the deltoid muscle, as illustrated. Depending on the fracture morphology and foreseen osteosynthesis the extensions of the skin incision may vary but may not extend more than 5 cm distally to the acromion, to protect the axillary nerve.

25. POSITION Beach chair : Head holder/shoulder positioner, Waist flexed 45 degrees, knees bent 30 degrees. Supine : Bump under ipsilateral scapula, rotating the trunk 30 degrees toward opposite side. Shoulders draped free to the level of medial scapular border.

26. Fixation using proximal humerus locking plate[PHILOS PLATING] The inability of conventional plates and screws to resist varus deforming forces in the proximal humerus,particularly if the bone is osteoporotic ,has led to locking plate fixation being used for these fractures Several clinical studies have shown high rates of healing and excellent functional recovery with proximal humerus locking plates . Plate designs vary in terms of the number of proximal screws and their arrangement ,as well as the ability to place screws at different angles with regard to the plate A plate is selected to allow at least three screws to be placed into the distal shaft segment .the plate position is also selected to avoid subacromial impingement and to allow two screws to be placed into inferomedial aspect of the humeral head A minimum of five or six screws are routinrly placed into the proximal segment .screw placement should be performed by drilling through the near cortex only, this avoids perforation of the articular surface. Once the plate and the screws have been placed transtendinous sutures are tied onto the plate to provide additional fixation

27. POST OP CARE Patients are followed at 2weeks,6weeks, and 3months after surgery Patients are immobilized for 6weeks in a sling while active range of motion exercises of the elbow ,wrist, and hand are encouraged Depending on the fracture pattern and stability that was achieved, passive range of movements is started between 2 and 4 weeks after surgery with forward elevation ,external rotation and pendulum exercises If healing has adequately progressed both clinically and radiologically at 6weeks active assisted range of movements started .

28. CLOSED REDUCTION AND PERCUTANEOUS FIXATION USING K-WIRES It has theoretical advantage of minimizing soft tissue trauma ,thereby promoting healing and reducing the risk of AVN of the humeral head. It also has the advantage of decreased scarring in the scapulohumeral interface and subsequent easier rehabilitation . Indications; Fracture without significant communition in pt with good quality bone Pt should be willing to comply with post op care plan Contraindications Severe communition and osteopenia are absolute contraindications Inability to reduce fracture fragments Fracture dislocation Non compliant patient

29. Two-part, three-part, and valgus-impacted four-part fractures of the proximal humerus can be treated with closed reduction and percutaneous fixation (CRPF) by surgeons that have a thorough understanding of the radiographic morphology of the proximal humerus , as assessment of fracture reduction will rely entirely on fluoroscopic imaging. Bone quality plays an important role in achieving adequate fixation with CRPF and to avoid pin migration and construct failure. Integrity of the medial hinge and periosteal continuity, in the absence of gross tuberosity migration, are important for CRPF to be successful.

30. For percutaneous K wiring CR by manual traction and mobilisation of the arm, then confirmed the reduction using an image intensifier. An assistant maintained the reduction,and percutaneous pinning was performed. Three to five 2 –2.5 - mm K - wires were used for fracture fixation, depending on the stability. The K-wires were left protruding from the skin.

31. To avoid injury to axillary nerve ,lateral pins should enter the humeral cortex at a point at least twice the distance from the upper aspect of the head to the inferior head margin with a wire angulated 45degree to the cortical surface The end point for the greater tuberosity pin should be >2cm from the inferior most margin of the humeral head

32. POST OPERATIVE CARE Patients are followed weekly both clinically and radiographically to monitor fracture healing and detect any possible pin migration or skin problems . Patients are immobilized for 3 to 4 weeks in a sling , while active range-of motion exercises of the elbow, wrist, and hand are encouraged. Passive range of motion is started thereafter with forward elevation, external rotation and pendulum exercises. If healing has adequately progressed at 6 weeks the pins are removed under local anesthesia and active range of motion is started.

33. Postoperative Period and Functional Analysis At follow-up visits, arm pouch was applied to patients in both groups of patients. Patients in the K-wire group were advised to perform passive shoulder exercises for the first 2 weeks,active assisted exercises at 2 – 4 weeks, and active exercises after 4 weeks. K - wires were removed after 6 weeks. The plate group began passive exercises from the first postoperative day. Active assisted exercises were encouraged between 3 days and 2 weeks, and active exercises had begun by the end of 2 weeks. All patients were evaluated in the second, fourth, and , sixth, and twelfth months and then once per year during outpatient visits.

34. Outcome Measures for Proximal Humerus Fractures Radiographic Assessment Radiographic follow-up is usually performed at set intervals . these frequently being 6 weeks and 3, 6, and 12 months after injury or surgery

35. CLINICAL ASSESSMENT Patients were assessed by Constant Murley score . Constant Murley score is a 100 points scale composed of pain (15 points), activities of daily living (20 points), strength (25 points ), range of movements (40 points). Lowest being the worst outcome and highest scores means best outcome. <30 poor. 30-39 fair. 40-59 good. 60-69 very good. >70 excellent.

36. Pain Pain is a key component of patient satisfaction. It is frequently quantified using a visual analog scale (VAS) and reported as a value from 0 to 10 Range of Motion Active and passive forward elevation , abduction , external rotation , and internal rotation are frequently reported . The use of a standardized technique with a goniometer is important to achieve reproducible measurements. Strength Strength is frequently reported as a measure of the weight that can be lifted in a specific plane . The use of a dynamometer to assess strength in 90 degrees of abduction is often reported.

37. RESULTS Group A underwent ORIF with PHILOS Plate. Group B underwent CRIF with percutaneous K wiring.

38. RESULTS The CMS of the Kirschner wire (K - wire) and plate groups did not differ significantly (p = 0.82671). . 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. p valve we got 0.82671 so the study was statistically insignificant and so the results were comparable. The mean CMS values were 58.5 ± 15.04 for the PHILOS group and 59.4 ± 12.04 for the K - wire group . All fractures united 100%. One case had stiffness and the other one had impingement in the PHILOS group . In the K wire group, one case had infection .

39. DISCUSSION Percutaneuos fixation has its limitations of poor reduction of fracture fragments, pin tract infection and long period of recovery . But it has the advantages of less soft tissue stripping with less exposure, less blood loss and minimal invasiveness . ORIF with PHILOS plate for treatment of proximal humerus fractures has the advantages of accurate reduction, early mobilization , better fixation in osteoporotic bones and ease of reconstruction of Comminuted irreducible fractures. On the other hand it has the disadvantages of excessive soft tissue dissection and blood loss, risks of injury to the neurovascular structures and increased risk of avascular necrosis of humeral head .

40. In a study conducted by Fazalet al. it was seen that PHILOS plate fixation provided stable fixation with minimal implant problems and enabled early range of motion exercises to achieve acceptable functional results . In the present study it was concluded that PHILOS plate provides an excellent stable construct even in multifragmented osteoporotic proximal humerus fractures with the advantages of accurate reduction and early mobilization. Fixation with percutaneous K - wires may present an efficient treatment option for 2 or 3 part proximal humerus fractures with its advantages of minimal invasiveness and less soft tissue dissection . Better functional results were seen in patients treated with PHILOS plate than those treated with percutaneous K - wire fixation .

41. CONCLUSION Our study showed that in elderly population , with comminuted proximal humerus fractures can be successfully treated with percutaneous K - wire fixation, as well as with open reduction and internal fixation with PHILOS and both were equally successful. Although the r adiological results are slightly better with the PHILOS than percutaneous K-wire fixation, there is no difference in functional outcome. In elderly population , both the modalities of treatments give comparable results , K-wire fixation is preferred as it requires less intra-operative time, less blood loss, less trauma to soft tissues, less cost but it requires C-arm control. As other medical comorbidities accompany the elderly patients and as fitness for anaesthesia is sometimes in question, K-wire fixation is preferred

42. Both modalities of treatment were associated with complications. They were more severe in K-wire fixation group than PHILOS group due pin loosening in osteoporotic bones in the elderly . In the present study it was concluded that PHILOS plate provides an excellent stable construct even in multifragmented osteoporotic proximal humerus fractures with the advantages of accurate reduction and early mobilization.

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