MEHMET FATİH KORKMAZ, Neslihan AKSU, Abdullah GÖĞÜŞ, Mürsel DEBRE, AYHAN NEDİM KARA, Zekeriya Uğur IŞIKLAR

Proksimal humerus kırıklarında kilitli plak PHILOS ile internal tespit sonuçları

Amaç: Humerus proksimal ve diyafiz kırıkları, osteoporotik hastalarda sık görülen ve cerrahisi komplikasyonlarla seyreden sorunlu kırıklardır. Çalışmamızda AO/ ASIF grubu tarafından geliştirilen ve kilitli vidalarla sabit açılı stabilizasyon sağlayan yeni internal tespit sistemi PHILOS (Proximal Humeral Internal Locking System) ile tedavi edilen hastaların sonuçları değerlendirildi. Çalışma planı: Çalışmaya, proksimal humerus kırığı nedeniyle PHILOS plak sistemiyle tedavi edilen 41 hasta alındı. Hastalar 65 yaş altı (grup A) ve 65 yaş veya üstü (grup B) olarak iki grupta değerlendirildi. Grup A’da 24 hasta (12 erkek, 12 kadın; ort. yaş 47, dağılım 24-64); grup B’de 17 hasta (4 erkek 13 kadın; ort. yaş 78, dağılım 67-90) vardı. Radyografik olarak tüm kırıklar AO/ASIF ölçütlerine göre sınıflandırıldı. Grup A ve B’de sırasıyla 10 hasta ve iki hastada deltopektoral girişim; 14 hasta ve 15 hastada deltoid split girişim uygulandı. Ortalama 15 ay (dağılım 6-28 ay) takip süresi sonunda her iki grubun fonksiyonel ve radyografik sonuçları değerlendirildi. Sonuçlar: Constant omuz skoru grup A’da ortalama 95.0 (dağılım 74-100), grup B’de 92.8 (dağılım 72-100) bulundu (p>0.05). Deltopektoral ve deltoid split girişim uygulanan olgularda altıncı aydan sonra Constant skoru ve fonksiyonel açıdan fark saptanmadı. Hiçbir hastada kaynamama veya implant yetersizliği gözlenmedi. Komplikasyonlar şunlardı: Vidanın eklem içine girmesi (n=1), tüberkülum majus fragmanında deplasman (n=1) ile birlikte plağın oblik yerleşimi (n=1), yetersiz redüksiyon (n=4) ve başın varus pozisyonunda tespiti (n=3). Hiçbir olguda avasküler nekroz görülmedi. Çıkarımlar: Kilitli vida plak sistemi, özellikle osteoporotik kırıkların tespitinde bugüne kadar kullanılan osteosentez yöntemlerinden, erken harekete izin vermesi ve implant yetersizliği olmaması nedeniyle üstündür.

Anahtar Kelimeler:

İleriye dönük çalışma, Tedavi sonucu, Kırık iyileşmesi, Omuz kırıkları, Kemik vidaları, Kırık tespiti, internal, Kemik plakları, İzleme çalışmaları

The results of internal fixation of proximal humeral fractures with the PHILOS locking plate

Objectives: Proximal and diaphyseal humeral fractures are common especially in the elderly, presenting as a challenging problem due to their high complication rates following surgical treatment. In this prospective study, we evaluated the results of patients treated with the PHILOS (Proximal Humeral Internal Locking System) locking plate, a new technique recently developed by the AO/ASIF. Methods: Forty-one patients who were treated with the PHILOS plate for proximal humeral fractures were evaluated in two age groups. Group A included 24 patients (12 males, 12 females; mean age 47 years; range 24 to 64 years) younger than 65 years, and group B involved 17 patients (4 males, 13 females; mean age 78 years; range 67 to 90 years) at or above 65 years. Radiographically, all fractures were classified according to the AO/ASIF system. Surgery was performed with the deltopectoral approach in 10 and two patients, and with a deltoid split in 14 and 15 patients in group A and B, respectively. Functional and radiographic results were evaluated after a mean follow-up of 15 months (range 6 to 28 months). Results: The mean Constant scores were 95.0 (range 74 to 100) and 92.8 (range 72 to 100) in group A and B, respectively (p>0.05). After six months of surgery, Constant scores and functional outcomes were similar in patients operated on with the deltopectoral approach or deltoid split. There was neither nonunion nor implant failure. Complications included intra-articular screw penetration (n=1), displacement of the greater tuberculum (n=1) with oblique placement of the plate (n=1), insufficient reduction (n=4), and varus displacement of the humeral head (n=3). No avascular necrosis was seen. Conclusion: Locking plate system is superior over other means of fixation methods, particularly in osteoporotic fractures, because it allows early rehabilitation and does not result in implant failure.

Keywords:

Prospective Studies, Treatment Outcome, Fracture Healing, Shoulder Fractures, Bone Screws, Fracture Fixation, Internal, Bone Plates, Follow-Up Studies,

___

1. Nayak NK, Schickendantz MS, Regan WD, Hawkins RJ. Operative treatment of nonunion of surgical neck fractures of the humerus. Clin Orthop Relat Res 1995;(313):200-5.
2. Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin Orthop Relat Res 2004;(419):46-50.
3. Neer CS II, Rockwood CA. Fractures and dislocations of the shoulder. In: Rockwood CA Jr,, Green DD editors. Fractures. Vol. 1, Philadelphia: J. B. Lippincott; 1975. p. 686-7.
4. Neer CS II. Displaced proximal humeral fractures. Part I. Classification and evaluation. J Bone Joint Surg [Am]1970;52:1077-89.
5. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res 1982;(167):255-9.
6. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001;72:365-71.
7. Nordqvist A, Petersson CJ. Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 1995;4:107-12.
8. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg [Am] 2002;84:1919-25.
9. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-6.
10. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res 1983;(179):116-28.
11. Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y. Prognostic factors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma 2003;17:181-8.
12. Demirhan M. Factors affecting the results of hemiarthroplasty for proximal humerus fractures. [Article in Turkish] Acta Orthop Traumatol Turc 2000;34:463-74.
13. Müller ME, Nazarian S, Koch P, Schatzker J, editors. The comprehensive classification of fractures of long bones. Berlin: Springer; 1990.
14. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;(214):160-4.
15. Kuner EH, Siebler G. Dislocation fractures of the proximal humerus-results following surgical treatment. A follow-up study of 167 cases. Unfallchirurgie 1987;13:64-71. [Abstract]
16. Wanner GA, Wanner-Schmid E, Romero J, Hersche O, von Smekal A, Trentz O, et al. Internal fixation of displaced proximal humeral fractures with two one-third tubular plates. J Trauma 2003;54:536-44.
17. Rowles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg [Am] 2001;83:1695-9.
18. Zyto K, Ahrengart L, Sperber A, Tornkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg [Br] 1997;79:412-7.
19. Speck M, Regazzoni P. 4-fragment fractures of the proximal humerus. Alternative strategies for surgical treatment. Unfallchirurg 1997;100:349-53. [Abstract]
20. Park MC, Murthi AM, Roth NS, Blaine TA, Levine WN, Bigliani LU. Two-part and three-part fractures of the proximal humerus treated with suture fixation. J Orthop Trauma 2003;17:319-25.
21. Sehr JR, Szabo RM. Semitubular blade plate for fixation in the proximal humerus. J Orthop Trauma 1988;2:327-32.
22. Seidel H. Humeral locking nail: a preliminary report. Orthopedics 1989;12:219-26.
23. Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg [Am] 2003;85:1215-23.
24. Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with the Polarus nail. J Shoulder Elbow Surg 2001;10:7-10.
25. Sadowski C, Riand N, Stern R, Hoffmeyer P. Fixation of fractures of the proximal humerus with the PlantTan Humerus Fixator Plate: early experience with a new implant. J Shoulder Elbow Surg 2003;12:148-51.
26. Herscovici D Jr, Saunders DT, Johnson MP, Sanders R, DiPasquale T. Percutaneous fixation of proximal humeral fractures. Clin Orthop Relat Res 2000;(375):97-104.
27. Cordasco F A, Bigliani LU. Complications of proximal humerus fractures. Tech Orthop 1997;12:42-50.
28. Lill H, Hepp P, Korner J, Kassi JP, Verheyden AP, Josten C, et al. Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens. Arch Orthop Trauma Surg 2003;123:74-81.
29. Frigg R. Development of the locking compression plate. Injury 2003;34 Suppl 2:B6-10.
30. Ring D, Jupiter JB. Internal fixation of the humerus with locking compression plates. Tech Shoulder Elbow Surg 2003;4:169-74.
31. Bernard J, Charalambides C, Aderinto J, Mok D. Early failure of intramedullary nailing for proximal humeral fractures. Injury 2000;31:789-92.
32. Peter CS, Wolfgang K, Norbert PS. Locking plate fixation of proximal humerus fractures. Tech Shoulder Elbow Surg 2005;6:8-13.
33. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Relat Res 2006;(442):115-20.
34. Charalambous CP, Siddique I, Valluripalli K, Kovacevic M, Panose P, Srinivasan M, et al. Proximal humeral internal locking system (PHILOS) for the treatment of proximal humeral fractures. Arch Orthop Trauma Surg 2007;127:205-10.
35. Siffri PC, Peindl RD, Coley ER, Norton J, Connor PM, Kellam JF. Biomechanical analysis of blade plate versus locking plate fixation for a proximal humerus fracture: comparison using cadaveric and synthetic humeri. J Orthop Trauma 2006;20:547-54.
36. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21:185-91.