INTRODUCTION:

Fractures of the proximal humerus account for 5% of all fractures and have a bimodal age distribution. In elderly individuals, it usually occurs following a trivial injury such as a slip and fall and the bone fractures due to its osteoporotic nature^1,2. In the younger age group the bone is quite strong and it requires a higher amount of force in order to cause a fracture and it usually happens following road traffic accidents and injuries such as fall from a height. Stable two part and undisplaced fractures are quite easy to manage and they can often be treated conservatively while complex 3 and 4 part fractures are unstable and they pose problems with difficulty in reduction and fixation and are associated with increased morbidity to the patient^3,4.

The aim of treatment for these fractures is to provide a stable and pain free shoulder and to facilitate return to activities of work and daily living at the earliest. Stable and undisplaced fractures especially in the elderly age group can be managed conservatively with strapping and cuff and collar for a period of 3 weeks but they can be associated with complications such as nonunion, malunion, shoulder stiffness and avascular necrosis. In fractures with comminution associated with displacement and head impaction, surgical management would be the ideal treatment option. The various modes of surgical management available are closed reduction with K wire fixation, ORIF with T and buttress plates, tension band wiring and hemiarthroplasty but all these options are associated with high rates of mechanical failure and complications^5,6,7,8. Recent advances in implant fixation technology have brought about the development of fixed angle locking plates as in the PHILOS plate which provide good angular and axial stability. These plates provide a stable internal fixation with decreased soft tissue stripping and dissection thereby preserving the blood supply to the bone. The plate is anatomically precontoured to conform to the shape of the proximal humerus and provides good angular stability. It permits fixation of locking screws through the plate which provide good purchase in osteoporotic bone. The screws have a wide angle of throw through the plate which aids in a solid fixation to the bone. There are holes in the plate through which suture anchors can be affixed to aid in repair of the rotator cuff. The shaft of the plate has combi holes which can accommodate both locking and cortical screws^[9]. The PHILOS plate has lower rates of implant failure as compared to other hardware and leads to better clinical and functional results. The aim of this study was to evaluate the functional outcome of Neers 3 and 4 part fractures following ORIF with PHILOS plate.

MATERIALS AND METHODS:

This was a prospective study of 30 patients with complex proximal humerus fractures who presented between June 2013 to June 2016 treated with ORIF with PHILOS plating and followed up for a period of 3 years. The study was performed after obtaining appropriate clearance from the ethical committee of our institution. All skeletally mature patients with Neers 3 and 4 part fractures willing for the procedure and follow up were included in the study while paediatric fractures, Neers 2 part fractures, patients not willing for follow up, compound fractures and patients with active infection or inflammation in the affected limb were excluded. At the time of admission, the shoulder was stabilized with a sling/cuff and collar and the patients were evaluated clinically and radiologically. Standard radiographs taken included an AP, lateral and axillary views. CT scans were taken in fractures with extensive comminution in order to visualize the fracture geometry and to plan for surgery accordingly. Routine blood investigations were done and the patients were worked up for the surgical procedure. Proper informed and written consent was obtained from the patients prior to the procedure. All surgeries were performed by the same orthopaedic surgeon who was well versed with the procedure. The procedures were performed under either regional or general anaesthesia under antibiotic cover. A dose of injection Cefazolin 1 gm was given at the time of induction of anaesthesia. The patient was placed in the beach chair position and a standard deltopectoral approach was used to expose the proximal humerus and the fracture site. The comminuted fragments were provisionally reduced and fixed with K wires under fluoroscopic guidance and the tuberosities were approximated with ethibond sutures. In case of impacted head fractures, the head was first elevated with a bone tamp followed by approximation of the greater and lesser tuberosities. The PHILOS plate was placed about 8 to 10 mm distal to the greater tuberosity in order to avoid impingement postoperatively. Locking screws were then placed in the various angled holes to get a good purchase in the subchondral bone. Care was taken to avoid joint penetration by the screws by putting the humeral head through internal and external rotation and obtaining fluoroscopic pictures to confirm the same. We routinely used an inferior calcar screw also known as the kickstand screw to provide more stability to the medial cortex and to prevent varus collapse. The 3.5 mm cortical screws were then applied to the shaft and position checked in AP and lateral views to confirm that the plate was well aligned to the shaft. The shoulder was then put through its range of motion and the stability of fixation was then assessed. The rotator cuff was repaired with suture anchors which were placed through specific holes in the plate. A thorough wound wash was then given and after ensuring haemostasis and placing a drain insitu, the wound was closed in layers and sterile dressing and a compression bandage was applied. Pendular shoulder exercises were started on the same evening of the surgery and the elbow was mobilized as well. Active range of movement exercises were then started on the first postoperative day based on patient compliance and pain tolerance. Wound inspections were done on the 3^rd and 5^th postop day and the drain tube was removed at the time of the first wound inspection. Suture removal was performed on the 12^th day. Radiographs were taken to assess the quality of fracture reduction and fixation. The patients were then discharged and were asked to review at time frames of 1,3,6 months and at yearly intervals thereafter. The patients were assessed radiologically for signs of fracture union and functional assessment was performed using the DASH and Constant and Murley side and the findings were documented in the case records. The data collected was analyzed using IBM SPSS Version 22.0. Armonk, NY:IBM Corp. Chi square test was used in the comparison of categorical variables. A P value of less than 0.05 was considered to be statistically significant.

RESULTS:

The mean age of the patients was 45.03 years ranging from 24 to 65 years. There was a male preponderance seen in our study with the right side being more commonly affected. The most common mode of injury were road traffic accidents followed by fall from height. There were 18 patients with Neers 3 part fracture while 12 patients presented with 4 part fractures. The mean time from injury to presentation to the hospital was 4 days ranging from 1 to 6 days while the mean time from presentation to the surgical procedure was 3 days ranging from 2 to 7 days. The mean surgical time was 92.4 minutes ranging from 78 to 110 minutes. The average blood loss encountered was 190.16 ml ranging from 135 to 250 ml. We were able to achieve a 100% union rate in our series. (Figure 1)

A. Preoperative radiograph. B. Immediate post op. C. 3^rd month AP. D. 3^rd month lateral

Figure 1: Illustrative case

Table 1: Patient demographics and data

S. No	Age	Sex	Side	Mode of injury	Neer type	Surgical time(mins)	Blood loss (ml)	Fracture union (weeks)	DASH score (3 m)
1	32	M	R	RTA	3	84	150	10	24
2	56	F	R	SAF	4	80	140	11	28
3	41	M	L	FFH	4	96	135	11	26
4	38	M	R	RTA	3	78	160	12	32
5	65	F	L	SAF	3	84	140	10	31
6	51	M	R	FFH	4	92	200	12	28
7	42	M	L	RTA	4	110	250	14	23
8	50	F	R	FFH	4	78	180	11	31
9	47	F	R	RTA	3	94	200	10	36
10	54	F	R	FFH	4	86	220	12	24
11	58	M	R	FFH	3	94	230	14	28
12	32	F	L	SAF	4	104	210	13	31
13	24	F	R	RTA	3	100	180	12	36
14	36	M	L	RTA	4	90	170	11	21
15	45	F	L	FFH	3	88	180	13	19
16	51	F	R	FFH	3	93	190	14	28
17	60	M	L	SAF	3	84	200	11	34
18	54	M	R	FFH	3	98	220	10	31
19	43	M	R	RTA	3	104	210	12	36
20	51	F	L	SAF	4	90	180	13	21
21	47	F	R	RTA	4	84	190	12	19
22	41	M	R	RTA	3	92	210	13	28
23	54	M	L	SAF	3	86	180	12	34
24	60	F	R	SAF	3	94	140	11	31
25	32	M	R	RTA	3	115	180	10	26
26	39	F	L	RTA	4	86	190	13	32
27	28	M	R	RTA	3	98	220	12	38
28	30	M	L	RTA	4	94	150	14	36
29	54	F	L	SAF	3	98	190	13	34
30	36	M	R	FFH	3	100	200	12	32

RTA- Road traffic accident. SAF-Slip and fall. FFH-Fall from height.

The mean time to fracture union was 11.9 weeks with a range of 10 to 14 weeks. The average range of movements of the shoulder achieved were: Abduction-135⁰_,Flexion-115⁰, External rotation-58⁰ and External rotation-60⁰. The average DASH score at 3 months was 22.5±26.2 while it was 8.9±6.4 at 1 year. The mean Constant and Murley score was 64.5±7.2. (Table 1) We had complication such as superficial skin infection in 2 patients which settled down with a course of antibiotics, mild varus fixation in 3 patients which was well tolerated and did not cause any functional disability to the patient and 1 patient had a screw backout for which metal exit was done 1 year after union of the fracture. We had no complications such as nonunion, malunion, loss of fixation, hardware breakage, impingement, deep infection or AVN seen in our study. All patients were satisfied with the functional outcome achieved. None of our patients were lost to follow up.

DISCUSSION:

Management of stable, undisplaced two-part fractures of the proximal humerus can be done by conservative means to bring about a good functional outcome but Neers 3 and 4 part fractures remain quite challenging to treat due to the complex nature of the fracture patterns associated with gross comminution and osteoporosis. Various surgical modalities are available for management such as closed reduction and percutaneous pinning, ORIF with buttress plates, tension band wiring, hemiarthroplasty and intramedullary nails. Closed manipulative reduction with percutaneous pinning is associated with complications such as improper reduction, migration of the wires and secondary collapse at the fracture site. Tension band wiring is commonly used but is has proven to produce a similar outcome as compared to conservative management hence is not the treatment of choice for surgical management. ORIF with T plates results in poor outcomes in osteoporotic bone and has been proven to be associated with complications such as screw backout, subacromial impingement and AVN (Avascular necrosis). Intramedullary nails show better results in 2 part fractures as opposed to 3 and 4 part fractures and the entry point can be difficult leading to comminution in the lateral metaphyseal region. The various complications associated with ORIF with plate osteosynthesis in unstable fracture patterns are nonunion, malunion, screw backout or cut through, varus collapse of the fracture, subacromial impingement and AVN. There is often a high incidence of these complication in the elderly age group due to osteoporotic quality of the bone¹⁰. AVN is the most dreaded complication and is commonly seen in complex fracture patterns with gross comminution leading to a compromise of the blood supply. Excessive soft tissue stripping and dissection during the surgical procedure further compound the issue and is more commonly associated with the conventional plates used. In this scenario locking plates are associated with less dissection and soft tissue stripping during plating and hence serves to preserve the blood supply to the bone. To prevent implant failure, it is essential to place the plate in a proper position with enough screws in the humeral head to provide a good purchase. The aim is to provide multiple divergent screws in the head to provide more stability^11,12. In our procedures, we used about 5 to 6 screws proximally and also used a calcar/kickstand screw in the inferomedial aspect in order to prevent varus collapse at the fracture site. Varus reduction is something which needs to be avoided as it has shown to lead to failure of fixation in many cases. Proper placement of the plate is essential and the ideal placement would be 8 to 10 mm from the greater tuberosity in order to prevent impingement. P. Moonot et al studied 32 patients with 3 and 4 part fractures and reported that 97% of fractures united clinically and radiologically. The mean time to fracture union was 10 weeks and the Constant and Murley score was 66.5 at time of last follow up. They had complications such as nonunion, malunion and broken screw in 1 case each¹³. In Emanual V et al study of 28 patients, 71.4% of the fractures united in a good anatomical position and the Constant score was 57.9±21.7. They reported excellent results in 57.1% patients and had complications such as AVN, screw loosening and subacromial impingement¹⁴. Jan-Magnus et al studied 72 patients with a 1 year follow up and reported that48 fractures united in a good anatomical position. They had 4 excellent outcomes with 32 patients having a good score. Complications such as nonunion in 2 patients, AVN in 3 patients were seen while 1 patient had a loss of fixation¹⁵. In our study of 30 patients, we were able to achieve 100% union of fractures with the mean time to fracture union being 11.9 weeks. The average DASH score at 3 months was 22.5±26.2 while it was 8.9±6.4 at 1 year. The Constant and Murley score was 64.5±7.2. We had complications such as superficial skin infection in 2 patients which settled down with a course of antibiotics, mild varus fixation in 3 patients which was well tolerated and did not cause any functional disability to the patient and 1 patient had a screw backout for which metal exit was done 1 year after union of the fracture. We had no complications such as nonunion, malunion, loss of fixation, hardware breakage, impingement, deep infection or AVN seen in our study. All patients were satisfied with the functional outcome achieved. None of our patients were lost to follow up. Overall the results of our study were promising with less complications. We hereby conclude by stating that ORIF of complex proximal humerus fractures with PHILOS plating is a good treatment option which provides good axial and angular stability. The locking screws provide good purchase in osteoporotic bones and gives good union rates resulting in better functional outcomes.

CONCLUSION:

The PHILOS plate is a versatile implant in the management of complex 3 and 4 part fractures of the proximal humerus. It provides multiple divergent screw options for securing optimum purchase in osteoporotic bone, requires less soft tissue stripping and dissection and aids in preserving the blood supply to the bone and leads to good union and better functional outcomes to the patient.

CONFLICT OF INTEREST:

The author declares no conflict of interest.

ETHICAL APPROVAL:

Approval taken from the ethical committee.

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Received on 18.07.2020 Modified on 17.05.2021

Research J. Pharm. and Tech. 2022; 15(6):2508-2512.

DOI: 10.52711/0974-360X.2022.00419