Proximal humerus fractures (PHFs) make up around 4-5% of all fractures and are the second most common kind of fracture in the elderly population, behind hip fractures and distal radius fractures. The prevalence of this condition is around 3 cases per 10,000 individuals per year and shows a significant upward trend with advancing age [1-3].

Most patients with this fracture are older, which heightens the likelihood of their bones being osteoporotic or brittle. The quality of the bone appears to be essential for both the surgical procedure and the functional result [2]. Moreover, the physical and occasionally cognitive vulnerability of an aged patient might provide challenges throughout the process of rehabilitation to regain their usual condition [2-5]. Most pathological humerus fractures (PHFs) are a result of low energy trauma, such as a fall from a standing posture while extending the arm [2-5]. Proximal humerus fractures remain a substantial and rising medical concern due to the significantly related morbidity and epidemiological trends indicating an aging population [3, 5].

Various therapy approaches have been employed in the past. These include trans-osseous suture fixation, tension band wiring, conventional plate and screw fixation, hemi replacement arthroplasty, percutaneous wire, and screw fixation. But no consensus is known on the optimal treatment technique especially of 3-part and 4-part fractures. Pre-contoured locking plates function on the idea of angular stability, less disruption of vascularity, and reduced risks of plate failure. The Proximal humeral internal locking system (PHILOS) plate fixation gives more angular stability than the conventional implants. It functions as a locked internal fixator and enables improved anchoring of screws in osteoporotic bone, with good functional results. In proximal humerus fractures, PHILOS plate delivers a satisfactory functional result with respect to the early joint mobilisation and stiff fixation of the fracture. The locking plate can be utilized with a minimally invasive procedure which permits indirect fracture reduction thus minimizing the probability of avascular necrosis (AVN) and also lowering of time of immobilization minimizes the possibility of frozen shoulder. Furthermore, the proximal locking screw having the capability of being applied in various directions makes it a fixating device with a high stability in osteoporotic bones. Despite the diversity in fixation methods and technical evolution, publications continue to demonstrate variety of problems like insufficient reduction, subacroimial impingement, adhesive capsulitis, malunion in varus position, migration of screws etc [6-8]. Frankhauser et al [6] and Duralde and Leddy [8] reported complication rates of 20-30% with locking plates such as pseudarthrosis, insufficient reduction, subacroimial impact, nerve damage and infection. Miyazaki AN et al [9] reported total complication rate of 35.7% with PHILOS plating. Considering the advantages of PHILOS plating and the scarcity of data on the complications, efficacy and the functional outcome following internal fixation with PHILOS plate for displaced proximal humerus fractures, the present study was planned to analyse complications and overall outcome at our center. Neer's classification was used to categorize fractures.Detailed physical examination and relevant investigations were done before to surgery. All patients were advised with treatment choices and decision regarding the operation was determined in consultation with patients. Informed consent was acquired from all patients. Associated injuries, if any, were treated as required.Operative Technique: All patients got a prophylactic dose of antibiotic intravenously preoperatively. A deltopectoral approach was done in beach chair posture under brachial block or general anesthesia. The fracture location was exposed and minimized with minimum soft tissue dissection.Briefly, the anatomical link between humeral head and larger tuberosity was decreased and secured temporarily using K wires. In case of evident rotation or displacement of the humeral head, a joy stick approach was applied. Then the shaft fragment was decreased by abduction, traction and rotation of the arm. The pieces were indirectly decreased with the use of traction sutures, which are put in the insertions of rotator cuff tendons, and by extremity rotation. When acceptable reduction is attained, the PHILOS plate was placed at least 1 cm distal to the upper end of the greater tuberosity and fastened to the humeral shaft. A targeting device is then affixed to the upper section of the plate, and the head fragments are fastened with Kirschner wires, following image intensifier control. The needed lengths of the locking head screws is measured with a direct measurement equipment, and four to six locking screws are then installed using a specially designed hexagonal screw driver. Proximal locking screws were placed to secure the humeral head.

After surgery, the shoulder was immobilised in a universal shoulder immobilizer. Appropriate antibiotics as well as analgesics were utilized. Immediate post-operative check radiographs were performed to assess the alignment of the bone and preservation of reduction. Post-operative care was given as per usual practice and early mobilization was started. Gentle pendulum exercises were started after a week as per comfort of the patient. ROM exercises were gradually increased with an intention to restore complete range of movement with terminal stretching exercises in 4-6 weeks. After suture removal by 12th day, patients were followed-up at 6 weeks, 3 months and 6 months for x-rays to assess the fracture union and functional result by utilizing Constant Shoulder Score

The study has been conducted after obtaining clearance from institutional ethical committee with informed consent from participating patients.Surgical procedure was carried out using a standard deltopectoral approach, with the patient in a beach-chair position. Postoperatively, the shoulder was immobilized in an arm sling. On the third post operative day, passive motion and pendulum exercises were initiated to prevent stiffness. Active assisted motion was limited to 40 degrees up to six weeks. Resistive strengthening was begun after fracture union had been ensured. All patients received a similar physical therapy program.

Study Area

SRI AUROBINDO INSTITUTE OF MEDICAL SCIENCE AND PG INSTITUE

Patients attending OPD and emergency in the age  of >18 years with intra- articular fracture proximal  humerus .

Inclusion criteria:

1. All patients with 2 part3-part or 4-part closed proximal humeral fractures (according to the Neer classification system) & Age >18 years
2. Closed Fractures.

Exclusion criteria:

1. Polytrauma patients
2. Head injury patients
3. Fractures with vascular damage.
4. Fractures with compartment syndrome.
5. Fractures with substantial soft tissue injuries.
6. Medically unsuitable patient

Sample Size: 30 patients

Sample Design: Selective sampling of cases meeting the inclusion criteria.

Study Design: It was a prospective study. The patients were assessed comprehensively with focus on radiological, functional, socioeconomic condition. Operative intervention was done in due course and post op follow up done at 6,12,24 weeks for any problems and morbidity using Constant Shoulder Score. Pre and after surgical radiological and functional result was compared.

CASE 1

pre op x ray     post op x ray

6 month follow up x ray

CASE 2

pre op x ray     post op x ray

6 month follow up x ray

CASE 3

pre op x ray     post op x ray

6 month follow up

6 month follow up x ray

Thirty patients with displaced proximal humerus fractures were treated with PHILOS plating. Out of 30 patients, 15 had 2-part fracture, 11 patients had 3-part fracture and 4 patients had 4-part fractures. The mean age of the patients was 47 ± 16 years (Range 31-63 years). Majority of the patients (68%) were men (20 males and 10 females). The male to female ratio was determined to be 2:1. Most of the patients indicated road traffic collision as the cause of trauma (50%) and involvement of left side was more prevalent (58%). Maximum (53.1%) patients had 2-part fracture according to Neer’s classification. The typical period for radiological union was 13 weeks (10-24 weeks). The range of motion during first, second and third follow ups increased progressively throughout consecutive follow ups. According to Constant Shoulder ratings most of the patients had outstanding result (50%) followed by good. (21.9%), fair (12.5%) and bad outcome (15.6%). Analysis of complications indicated that there were 4 instances of insufficient reduction, 2 cases of sub-acromial impingement and 1 case of frozen shoulder. One patient experienced varus malunion of the fracture. There were no incidences of nerve damage, infection, implant failure or non-union.

In our research, total of 7 individuals out of 30 developed problems (21.8%). In literature, the reported complication rates are ranging from 3.7% to 35.7% [9, 11, 12] The primary consequence in our research was insufficient reduction of the fracture (Fig. 1).

There were 4 occurrences (13.4%) which were predominantly related with 3 and 4 component fractures. In literature, 13.7% to 25% of patients had this problem [6, 13, 14] According to Koukakis et al [15] and Duralde and Leddy [8], key surgical problem is achieving fracture reduction to anatomical position and maintaining the position is a biggest obstacle. So we consider that comprehensive pre-op preparation with excellent quality x-rays, CT scan and enough training to develop surgical skill are important.
In our research, the second most prevalent consequence was subacromial impingement induced by the plate. We had 2 patients (6.6%) who had plate placement slightly higher than recommended location i.e. less than five millimeters from the apex of the larger tubercle [8, 16] The incidence of occurrence of this complication is around 0-12.5% in literature [6, 13, 15, 16]. To avoid this issue, location of the plate needs to be accurate and lower than 8mm from apex of the larger tubercle [9]. (Fig. 2). Loss of decrease in varus position is another key complication of the fixation. We had one instance (3.2%) which was repaired in varus position and healed with malunion.

Miyazaki et al [9] observed that 3.3% of their subjects suffered this problem. Varus malposition is defined as a head shaft angle of less than 120 degrees. According to Agudelo et al [13], primary varus reduction is a significant risk factor which may contribute to poor result. Our patient got unsatisfactory outcomes according to Constant shoulder score. We also had one incidence of adhesive capsulitis owing to insufficient Physiotherapy in a elderly patient resulting to unsatisfactory outcomes.The examination of functional outcome shows that 16 of our patients had outstanding result (50%) followed by good in 7 patients(21.9%), fair in 4 patients(12.5%) and bad outcome in 5 patients(15.6%). Overall, 71.9% of patients had outstanding to good outcomes while 28.1% of patients had fair to poor results.Geiger EV et al [17] observed outstanding to good outcomes in 57.1% patients, moderate in 3.6% and 39.3% unsatisfactory results.

Proximal humerus fractures might be one of the most damaging entities to treat. These fractures frequently exhibit a bimodal age distribution with high energy velocity injuries in younger population

to mild trauma in older age groups. Although, undisplaced fractures can be treated non-operatively with satisfactory result, fractures with intra-articular extension and extensive comminution need surgical fixation [9,10].

These fractures are difficult to handle conservatively due to their anatomical placement which makes bracing, ineffective. Surgical options such as percutaneous K wires are linked with less soft tissue damage, reduced blood loss and neurovascular injury. But these techniques do not assure consistent anatomical reduction and impede early mobility and fracture healing. Moreover, problems like pin tract infection and delayed mobilization, further curtails the indications for this surgery [11].

Options like multiloc nailing and plating each have their own advantages and downsides and the discussion for the ideal implant continues. Nailing being load sharing devices offer biomechanical advantage over plating systems. Hessmann MH et al., in their analysis of 160 patients during six months follow up revealed that 93.7% instances had good to outstanding outcomes as per the surgeon’s view [12].

Internal fixation using non-locking plates has led in poor clinical outcomes and significant failure rates in the past. Pre-countoured anatomical locking compression plates are more flexible with higher rates of union, particularly in osteoporotic bones [13,14].

They give more robust buttress laterally and the diverging screw options in the cancellous bone, making them the implant of choice in complicated fractures. The forces are passed from the bone to the screw head and subsequently to the plate and hence these plates have a higher stability than the non-locking plates. Siffri PC et al., in their cadaveric analysis revealed that locking plates had greater torsional stability as compared to non-locking plates [15]. Second generation locking plates encourages the use of anterolateral deltoid split technique to protect the blood supply of the humeral head, use of rotator cuff sutures, medial column stabilization and use of endosteal supports [13,15]. We have no experience with the second generation plates and deltoid splitting method. All the procedures executed in the current investigation were done utilizing the delto-pectoral approach.

There are minimal risks including plate breakage, screw cut out, avascular necrosis, varus mal reduction and revision surgery associated with the use of locking plates [16,17]. Owse ley KC and Gorczyca JT in their study of 53 patients reported a screw cut out rate of 23% [18]. They also claimed that screw cut out is one of the most prevalent causes for revision surgery. The percentage of screw cut out in the current investigation was 0 %. This failure may be ascribed to preponderance of the patients in senior age group with osteoporotic bones.

Fracture geometry also has a vital effect in the ultimate result.

Hertel R et al., in their series of 100 patients with intracapsular humerus fracture examined the perfusion with the use of Doppler study [19]. They developed a binary description system and concluded that anatomical neck fracture, shorter calcar and disruption of the posteromedial hinge when present together has a positive predictive value for ischemia of 97%. Avascular necrosis is another but delayed consequence which arises in three- and four-part fractures with extensive comminution. It frequently happens years after the fixation and may generate poor functional results [20,21]. Still, there are rare series which showed positive results in spite of avascular necrosis [22]. There was no instance of avascular necrosis encountered in the current investigation.

Reduction of the fracture is of essential significance in any surgery which holds true even for proximal humerus fractures.

Varus reduction is one of the severe intraoperative complications which are unaccepatble as it leads to early failure in most of the cases. In the current research, difficulties in reduction was observed in 3.2 % instances which contributed to varus collapse. These instances were revised with hemiarthroplasty owing to severe osteoporosis. In our experience, patients with two part fractures performed better as compared to three and four part fracture instances. Although, many individuals declare that the outcomes of hemiarthroplasty in three and four component fractures are superior than plating, current meta-analysis refute the same [22].

Proper placement of the plate is equally critical for a greater outcome in these fractures. These plates, unlike non-locking plates, are anatomically pre-countoured and so even a minor displacement might result in shoulder impingement. The optimal location of the top most extent of the plate is 5 mm-8 mm distal to the greater tuberosity as per the AO-OTA principles. There have been cases with shoulder impingement ranged from 1.8%-8% in the literature [23-27]. In contrast to the aforementioned investigations, there was 6.6% instance of impingement observed in the current research.

The average time for radiological union was 12±4.5 weeks which is consistent to the earlier research [7,17]. Final findings were compared with the research by Neer [28], utilizing the Neer's grading system which was statistically significant (p<0.05)

LIMITATIONS:

There are two major limitations to this study. Firstly, the number of patients was small. The reason for this is that we only included patients with complete data (i.e., radiographs, Constant-Murley score, DASH score).

Secondly, the effect of bone quality on secondary loss of reduction was not evaluated. Most patients did not receive bone density examinations on admission or during follow-up.

Finally, only simple radiographs were used to evaluate the loss of reduction during the follow-up. CT can more accurately assess the presence of reduction loss, but it is not realistic to perform follow-up CT for all patients.

PHILOS plate is the best available construct and a stable implant to utilize for fractures of the proximal humerus in Neer’s 2-part, 3-part, and 4-part and osteoporotic fractures of the proximal humerus, especially in older patients thereby permitting early mobility of the shoulder. However, issues including insufficient reduction, varus malalignment, subacromial impingement and frozen shoulder can still occur with this method as well. We have to remember that PHILOS is not a panacea for all the problems associated with proximal humerus fractures. We feel that despite the related complication rates, these plates operate marvelously in circumstances with severe osteoporosis and comminution.

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