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Fig 3a
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Three part fracture of the proximal humerus with metaphyseal comminution.
A prospective standardized international multicenter study of the PHN was performed to answer the following basic questions: • Is intramedullary nailing with a new angle stable titanium nail a safe procedure in the treatment of proximal humeral fractures • Does it provide a good outcome (Constant-Morley and DASH)?
Fig 3b
Stabilization with PHN and spiral blade.
Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related with a suboptimal surgical technique. The nail has not been properly introduced or the length for the spiral blade was not exactly determined and its correct position was not controlled intraoperatively (Fig 4). The development of nonunion (2/108) shows a ratio equal to or even better than what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments shows the limit of this procedure. In multifragmentary fracture types, one spiral blade will not be able to fix all fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach.
In 11 hospitals, 151 fractures had been treated, of which 72 were extraarticular unifocal A type (2 part), 67 extraarticular bifocal B type (3 part) and 12 intraarticular C type (4 part, valgus impacted) (AO-classification) (Fig 3a–c). There were 37 male and 114 female patients, median age 66 years, ranging from 16–97 years. In total, 108 patients could be followed up for one year. The important complications noted were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), displacement of fragments (n=2), nonunion (n=2), humeral head necrosis (n=3) and wound infection (n=1).
The study data as well as personal experience with the PHN since 2002 lead to the conclusion that proximal humeral nailing seems to be beneficial in A-type metaphyseal fractures, if not treated conservatively. Even in many B-type fractures it is still a good alternative with a more limited incision in comparison to plate osteosynthesis. In C-type fractures, nailing is not advisable as a standard routine.
The Constant-Morley score shows mean values of 75.3 on the injured side at one year postoperatively and 89.9 on the noninjured side. The mean DASH score was pre-operatively 5.9 and 9.3 at one year postoperatively. These results are similar to those with plate osteosynthesis. C-type fractures clearly have the worst prognosis.
Retrospectively, the initial idea of finding a nail solution for almost all fracture types in the proximal humerus is not realistic. Nevertheless, the PHN has a clear role in the repertoire of reliable implants for proximal humerus fracture fixation when minimal invasive approaches are desired and an anglestable plate is not necessary.
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22.11.2007 11:09:30 Uhr