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Open intramedullary nailing with tension band and locking sutures for proximal humeral fracture: Hot air balloon technique
Open intramedullary nailing with tension band and locking sutures for proximal humeral fracture: Hot air balloon technique Jin-Young Park, MD,a Jin-Woo An, MD,b and Jeong-Hwan Oh, MD,a Seoul and Cheonan, South Korea
To reduce complications and increase fixation after the internal fixation of proximal humeral fractures, interlocking intramedullary nailing and tension-band and locking sutures were used simultaneously, and their results are reviewed. Twenty-six consecutive patients who underwent open intramedullary nailing with tension-band and locking sutures for proximal humeral fractures were selected. The mean follow-up period was 39 months. With regard to the functional evaluation, the mean Neer score was 90 points and the mean American Shoulder and Elbow Surgeons score was 85. When patients were divided into those aged less than 65 years and those aged 65 years or greater and into those with 2-part fractures and those with 3-part fractures, postoperative pain, the American Shoulder and Elbow Surgeons score, and the Neer score showed no difference between the 2 groups. Open intramedullary nailing accompanied by tensionband and locking sutures for proximal humeral fractures shows sufficient fixation in older patients, and therefore, good postoperative shoulder function can be expected. (J Shoulder Elbow Surg 2006;15:594-601.)
P roximal humeral fractures account for 10% of all
fractures occurring in patients aged older than 60 years, and they comprise 45% of all humeral fractures.2 Although most proximal humeral fractures are treated conservatively,29,44 operative treatment is necessary when the fracture is markedly displaced or dislocated.8,15,23,27 Many methods are available for internal fixation of a From the aDepartment of Orthopaedic Surgery, Konkuk Medical School, Seoul, and bDepartment of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan. Supported by Konkuk University in 2005. Reprint requests: Jin-Young Park, MD, Shoulder, Elbow and Sports Service, Department of Orthopaedic Surgery, Konkuk University School of Medicine, 4-12, Hwangyang-Dong, Kwangjin-Gu, Seoul, 143-914, South Korea (E-mail: [email protected]). Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2006.01.001
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proximal humeral fracture, including wires,15,16,20,21 external fixation,5,24 Rush pins,40,43 metal plates,11,18,22 and intramedullary nails.26,33,39 Complications from these methods of fixation include fixation failure, impingement symptoms, pathology from the implants, and a decrease in shoulder function in displaced fractures in those patients with soft-tissue injury and severe osteoporosis.* We performed interlocking intramedullary nailing with placement of tension-band and locking sutures simultaneously for proximal humeral fractures to reduce the complications associated with internal fixation and to increase the fixation strength and then reviewed the results obtained. Our hypothesis is that tension-band and locking sutures with intramedullary nailing make early range of motion possible and give more stability compared with other techniques. MATERIALS AND METHODS In a retrospective study with a prospective protocol, 29 consecutive patients with proximal humeral fractures according to the classification of Neer29 underwent operative treatment between June 1998 and May 2001. Twenty-six cases with adequate follow-up form the basis for this study. The 3 cases with inadequate follow-up included 1 patient who died from stomach cancer metastasis, one who died after a cerebrovascular accident, and one who died from old age. The inclusion criteria for open intramedullary nailing combined with a tension-band and locking suture were 2- or 3-part fractures with severe comminution or osteoporosis and valgus-impacted 4-part fractures or fracture-dislocations (Figure 1). The exclusion criteria were as follows: patients who could be treated nonoperatively because their fractures lacked severe comminution, those who had a closed reduction and percutaneous pin fixation as a result of good bone quality of the proximal humerus as determined by bone mineral densitometry (dual-energy x-ray absorptiometry) (Norland XR-26 MARK II; Norland Corp., Fort Atkinson, WI), those with a 4-part fracture requiring humeral head replacement, those with a neglected fracturedislocation, and those with an isolated greater or lesser tuberosity fracture. For fracture classification, we used simple radiographs and 3-dimensional computed tomograms. The participants were 5 men and 21 women (Table I). *
References 1, 5, 8, 13, 15-17, 21, 22, 28, 30, 33, 34, 39, 41.
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Figure 1 Proximal humeral fracture combined with proximal humeral shaft fracture: Preoperative anteroposterior (A) and axillary lateral (B) views and postoperative anteroposterior (C) and axillary lateral (D) views at 2 years postoperatively.
Their mean age was 62 years (range, 27-79 years), and the mean follow-up period was 39 months (range, 24-59 months). The mechanisms of injury included motor vehicle accidents (2 cases) and pedestrian–motor vehicle accidents (7 cases). In addition, there were 13 cases of injury from a fall and 4 cases of a fall from a height. The mean time from injury to operation was 8 days (range, 0-27 days). A combined injury occurred in 14 of 26 cases. Combined neurologic injuries included radial nerve palsy (1 case) and brachial plexus injury (1 case). Anteroposterior bone mineral density from the second to fourth lumbar spine was measured in patients aged older than 50 years preoperatively (21 patients; mean age, 67 years). The mean bone mineral density was 0.74 g/cm2 (range, 0.57-1.02 g/cm2), and the mean T-score was ⫺2.6.
Operative technique The skin incision was performed via the deltopectoral approach with patients in the beach-chair position (Figure 2, A).15 To expose the humeral insertion of the supraspinatus and rotator interval, the leading edge of the coracoacromial ligament was removed.3 To reduce the incidence of avascular necrosis, only minimal removal of the periosteum necessary to visualize the fracture was performed. Direct manipulation of the fractured fragment was minimized by use of traction sutures on the rotator cuff attached to the greater or lesser tuberosity when a 3-part fracture was verified to be present (Figure 2, B). To reduce injury to the rotator cuff, the rotator interval was palpated and was incised parallel to the direction of the muscle fibers (Figure 3). The upper area of the humeral head was exposed by retracting the supraspinatus posteriorly and the long head of the biceps and the subscapularis anteriorly. In general, the center of the axis of the humeral shaft is located 8 mm
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toward the coronal plane and 3 mm posterior in the axial plane in relation to the center of the humeral head.4 This site is on the posterior side of the point at which the long head of the biceps comes out of the humeral head, and in this area, the point closer to the insertion site of the supraspinatus was chosen as the insertion site of the nail (Figure 3). In those cases of a surgical neck fracture, a guide wire was used to reduce the fracture and reaming was performed (Figure 2, C); the nail was then inserted into the humeral head, deeper than the articular cartilage, to prevent rotator cuff damage postoperatively. The Uniflex humeral nail (Biomet, Warsaw, IN) was used in 10 cases, and the Polarus nail (Acumed, Hillsboro, OR) was used in 16. The distal interlocking screw was inserted first. It was then determined whether the fractures of the greater or lesser tuberosity were reducible without tension (Figure 2, D). The 4 cases of a surgical neck fracture that showed a fracture line in the greater tuberosity underwent placement of locking sutures (horizontal intertuberosity sutures to assemble the greater and lesser tuberosity together) between the subscapularis and infraspinatus with No. 5 braided nonabsorbable sutures (Ethibond; Ethicon, Somerville, NJ) to increase the stability between the greater and lesser tuberosity (Figure 4). To prevent distraction and varus deformity between the humeral head and the shaft, tensionband sutures (vertical diaphyseal tuberosity sutures) were placed between the head of the distal interlocking screw and the supraspinatus, infraspinatus, and subscapularis by use of No. 2 or No. 5 braided nonabsorbable sutures (Ethibond) (Figure 5). Proximal locking screws were inserted to increase the rotational stability between the proximal humerus and the humeral shaft after superoinferior stability of the surgical neck fracture with the tension-band suture and stability between the greater and lesser tuberosity with the locking suture were obtained (Figure 3, E and F, and Figure 6). Autologous bone grafting was performed at the fracture site in 6 cases with 2- or 3-part fractures with severe comminution or osteoporosis and in 1 case with a 4-part fracture. Two cases of proximal humeral fracture combined with a shaft fracture also underwent bone grafting. After internal fixation, we confirmed whether the nail protruded above the humeral head. The incised rotator interval was sutured via a No. 2 nonabsorbable braided suture (Ethibond). One case with a massive rotator cuff tear underwent open repair. Acromioplasty was carried out in 9 patients who were identified to have a type II or III acromion with a spur, by abduction of the arm after internal fixation and palpation of the undersurface of acromion. No patient required a blood transfusion intraoperatively or postoperatively. In all patients, the proximal tip of the nail was located below the humeral head or at the same height; the nail was inserted on average 3 mm (range, 0-9 mm) deeper than the humeral head on postoperative radiography. The number of proximal interlocking screws averaged 3 (range, 2-4), whereas the number of distal interlocking screws averaged 2 (range, 1-2). Antegrade static interlocking nailing was carried out in all cases. All wounds were closed in layers with drainage, and the limb was put in an arm sling for 4 to 6 weeks. Systemic antibiotics with cefazolin and gentami-
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Table I Clinical data of patients with proximal humeral fractures treated by open intramedullary nailing with tension-band and locking sutures Range of motion No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Age (y)
Sex
Parts
AO/OTA Classification
Pain score
FE (°)
ER (°)
ER in 90° abduction (°)
IR
ASES score
Neer score
56 65 41 48 63 50 71 78 64 58 72 78 62 27 57 74 68 63 67 74 65 41 48 71 79 69
F F F M F M F F F M F F F M F F F F F F F F F F M F
2 2 2 3 3 2 3 3 3 3 3 3 3 3 2 3 2 3 3 3 3 3 3 4 3 2
B3 B2 B2 C1 C1 C3 C1 C3 B3 C1 C1 C1 B3 C3 B3 B2 B1 B1 C1 C2 B2 B2 C3 B2 B2 B3
1 3 1 2 1 1 2 3 0 1 1 1 2 1 0 0 0 0 0 0 1 1 2 1 0 6
140 120 150 140 90 150 140 100 150 150 150 120 150 150 150 140 140 150 150 150 150 150 160 140 140 90
60 30 70 40 30 70 0 40 50 30 50 30 50 50 60 30 50 70 45 40 50 50 70 60 45 10
80 50 70 70 30 90 40 70 80 70 60 50 70 80 70 80 75 80 70 60 60 80 80 80 70 30
T7 L2 T11 T12 L1 L2 L3 T11 T10 L5 T11 L2 L1 T10 T10 T11 T8 T11 T4 T8 T10 L5 T11 T12 L1 L5
90 72 92 77 83 88 73 68 87 95 92 77 80 85 98 92 92 93 100 98 92 88 87 82 88 40
95 76 98 85 90 92 80 75 98 88 92 86 92 95 99 97 96 99 98 99 98 89 92 86 92 45
FE, forward elevation; ER, external rotation; IR, internal rotation.
Figure 2 A, Exposure of proximal humeral fracture through deltopectoral approach. B, Traction sutures to greater or lesser tuberosity fragment were used for minimizing manipulation. C, Reaming of humeral head along guide wire after reduction between head and shaft fragment. D, Checking of fragment reduction by use of traction sutures. E, Operative finding in external rotation of humerus after internal fixation with intramedullary nailing and tensionband suture. F, Operative finding in internal rotation of humerus.
Figure 3 Exposure of humeral head through rotator interval (between supraspinatus and subscapularis) in surgical neck fracture and 3-part fracture. An incision was made at the anterior leading edge of the supraspinatus. The inlet of the intramedullary nail on the humeral head is situated at the medial side of the insertion of the supraspinatus and the posterior side of the long head of the biceps brachii.
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Figure 4 Locking sutures (No. 5 nonabsorbable braided sutures) were placed between the greater tuberosity and lesser tuberosity to increase the stability of the humeral head fragments.
cin were used for 3 to 7 days based on the status of wound healing.
Rehabilitation Postoperative abduction bracing or cast immobilization was not used. On the first day after the operation, pendulum exercises and passive forward elevation exercises of the shoulder joint were started. On the second day, a pulley exercise was performed, and in the fifth week after surgery, patients started external rotation exercises with a stick. Radiologic examinations were carried out at 6 and 10 weeks and 4 and 6 months after surgery, and active range of motion was allowed if bony union was identified in the sixth week or tenth week after operation.
Evaluations A visual analog pain evaluation with a scale ranging from 0 to 10 was carried out at the final follow-up. The functional evaluation of the shoulder joint used a 100-point score according to the evaluation of Neer29 and the evaluation of the American Shoulder and Elbow Surgeons (ASES)35 at the final follow-up. The ASES score was classified as excellent (91-100), good (81-90), fair (71-80), or poor (⬍70); of these, excellent and good scores were defined as satisfactory. A physician’s assistant determined the range of motion by measuring forward elevation of the shoulder, external rotation with the patient’s arm at the side, external rotation in 90° abduction, and internal rotation. All patients, except one, were followed up at monthly intervals until the fracture consolidation was apparent on X-ray and then reviewed at 3 monthly intervals for this study to record the functional
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Figure 5 Tension-band sutures were placed between the rotator cuff and distal interlocking screw to increase the stability of the surgical neck fracture by use of No. 5 nonabsorbable braided sutures.
outcome. If the final follow-up was not possible, a telephone survey was conducted. For statistical analysis, the Student t test was used for patients’ ages and range of motion by use of SPSS software, version 11.0 (SPSS, Chicago, IL), and the MannWhitney U test was used for pain, ASES scores, and Neer scores. Tests were considered statistically significant at P ⬍ .05.
RESULTS Bony union was obtained in 25 of 26 cases on final follow-up. The time to union averaged 8.7 weeks (range, 7-12 weeks). The mean operation time and blood loss were 2.1 hours (range, 1.5-3.2 hours) and 230 mL (range, 120-320 mL), respectively. The mean pain score was 1 point (range, 0-6). The mean Neer score was 90 points (range, 45-99) and was considered excellent in 18 cases, good in 5, and unsatisfactory or a failure in 3. The mean postoperative ASES score was 85 points (range, 40-100) and was considered excellent in 11 cases, good in 9, fair in 4, and poor in 2. The patient whose case was considered a failure by the Neer evaluation and who had a poor result by the ASES evaluation had a fracture-dislocation accompanied by a 2-part surgical neck fracture and a large Hill-Sachs lesion. This patient was admitted to our hospital for a loss of reduction at the fracture site 1 month after closed reduction and percutaneous pin fixation. Although open reduction–internal fixation was performed, a Bankart lesion repair was carried out because of redislocation. In the fourth month of
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Figure 6 Open intramedullary nailing with tension-band and locking suture resembling hot air balloon. The interlocking nail for rotational stability is the hot air, the locking sutures are the horizontal load tapes, and the tension-band sutures are the vertical load tapes. The load tapes share the stress about the explosive power of the balloon.
follow-up, humeral head replacement was performed because of the development of avascular necrosis. The patient who was considered to have an unsatisfactory result by the Neer evaluation and a poor result by the ASES evaluation had a 3-part fracturedislocation in the greater tuberosity and surgical neck. In this patient, postoperative nonunion and upward protrusion of the nail occurred. A humeral head replacement was performed for nonunion after 14 months. The patient whose case was considered a failure by the Neer evaluation and who had a fair result by the ASES evaluation was admitted for a loss of reduction after closed reduction with percutaneous pin fixation at another hospital. Combined injuries included an ipsilateral ankle fracture and a fracture in the thoracic spine. Although open reduction, internal fixation, bone grafting, and acromioplasty were car-
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ried out, we could not obtain an accurate reduction because of the delay in surgery. Postoperative angulation was 40° at the fracture site. The patient had muscle weakness and motion limitation postoperatively. Three cases had a satisfactory result by the Neer evaluation and a fair result by the ASES evaluation: two with 3-part fractures and combined extremity injuries and one with a surgical neck fracture and a cardiovascular condition. All had mild pain and limitation of range of motion. When patients were divided into those with 2-part fractures and those with 3-part fractures, postoperative pain, ASES, and Neer scores showed no significant differences (Table II), and when they were divided into those aged younger than 65 years and those aged 65 years or greater, postoperative pain, ASES, and Neer scores also showed no significant difference (Table III). Mean forward elevation was 139° (range, 90°160°) (7° decrease compared with contralateral shoulder), mean external rotation was 45° (range, 0°-70°) (11° decrease compared with contralateral side), mean external rotation at 90° abduction was 66° (range, 30°-90°) (5° decrease compared with contralateral side), and internal rotation was to the spinous process of the T12 vertebra (range, spinous process of T4 to L5) (decrease of 3 vertebral heights compared with contralateral side). Postoperative complications included nonunion (1 case), avascular necrosis of the humeral head (1 case), and protrusion of the proximal interlocking screw (1 case). There were no implant failures or superficial or deep infections. Two cases showed more than 20° of anterior angulation of the surgical neck (20° and 40°), and both patients had an unsatisfactory Neer score. More than 5 mm of malunion of the greater tuberosity was seen in 2 cases of malunion superiorly (5 mm and 8 mm) and in 2 cases of malunion inferiorly (5 mm and 8 mm). However, the treatment outcomes of these 4 cases were better than good with regard to the Neer and ASES scores (Figure 7). There were 3 cases of revision operations: 2 had humeral head replacements for avascular necrosis of the humeral head and nonunion and 1 had lysis of adhesions for a surgical neck fracture combined with a myositis ossificans after head injury. DISCUSSION Different forms of intramedullary nailing have been used for humeral fractures (eg, Rush rod, Enders nail, and Seidel nail) since Christensen7 used the Küntscher nail in 1976, and an interlocking nail has recently been introduced.14,36,40 The interlocking nail has advantages in that it can provide rotational
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Table II Operative results of proximal humeral fractures according to fracture patterns
Table III Operative results of proximal humeral fractures according to age at injury
Fracture pattern 2 Parts
>2 Parts
No. of cases 11 15 Male/female 2/9 3/12 Fracture pattern (No. of cases) 2 Parts 8 0 3 Parts 0 12 4 Parts 0 1 fracture-dislocation 1 1 Combined with shaft fracture 2 1 Pain scale (visual analog scale from 0 to 10) [mean ⫾ SD (range)] 1 ⫾ 2 (0–6) 1 ⫾ 1 (0–3) ASES score [mean ⫾ SD (range)] 84 ⫾ 17 (40–98) 86 ⫾ 8 (68–100) Neer score [mean ⫾ SD (range)] 88 ⫾ 16 (45–99) 91 ⫾ 7 (75–99)
stability of the fracture site after internal fixation, it can prevent superior migration of the proximal humerus, and it has a low possibility of nail protrusion.1,19,33 According to reported studies,1,33 in cases of surgical neck fractures and 3-part fractures of the proximal humerus, intramedullary nailing yields satisfactory results in more than 80%. However, Chapman et al6 reported that the use of a nail reduced shoulder function. The causes of this reduction were indicated to be impingement of the nail in the subacromial space,9 superior protrusion of the nail,10,37 protrusion of the screw,10,37 and rotator cuff injury.37 Fixation by use of a Rush rod and tension-band wiring38,40 or by use of the modified Enders nail and tension-band wiring have the problem of reduced shoulder function as a result of superior migration of the pin3 and nail.38,41,43 Although tension-band wiring has the problem of extending the posteromedial aspect of the fracture gap and cutting through it, Hawkins and Angelo15 improved this problem by using 2 pieces of tension-band wiring. As reported by Ruch et al39 and Weinstein et al,42 interlocking intramedullary nailing could increase banding and torsional strength. This was carried out in parallel with tension-band wiring, which was useful for proximal humeral fractures with osteoporosis. With this treatment method, a low rate of complications, including 1 case of protrusion of the proximal interlocking screw, 1 case of nonunion, and 1 case of avascular necrosis, was found, in addition to 6 cases of malunion, which were a result of a technical error during early series using the operation. Fixation by use of nonabsorbable heavy sutures yielded good results even though rotational instability occurred sometimes.12,31 Therefore, we used a com-
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Age <65 y
>65 y
No. of cases 13 13 Male/female 4/9 1/12 Fracture pattern (No. of cases) 2 Parts 4 4 3 Parts 6 6 4 Parts 0 1 Fracture-dislocation 0 2 Combined with shaft fracture 3 0 Pain scale (visual analog scale from 0 to 10) [mean ⫾ SD (range)] 1 ⫾ 1 (0–2) 1 ⫾ 2 (0–6) ASES score [mean ⫾ SD (range)] 88 ⫾ 6 (77–98) 82 ⫾ 16 (40–100) Neer score [mean ⫾ SD (range)] 91 ⫾ 6 (77–99) 83 ⫾ 14 (45–99)
Figure 7 Postoperative radiograph showing inferior malunion of greater tuberosity.
bined technique with interlocking intramedullary nailing and heavy sutures. We carried out the following operative techniques to minimize the loss of shoulder function that may occur after internal fixation by use of a nail: First, the humeral head was exposed through the rotator interval to reduce the loss that may occur by the incision of the rotator cuff. Second, if a nail with an 11-mm proximal diameter is inserted into the rotator cuff when the insertion area of the supraspinatus is considered to be 374 mm2, a 25% loss of insertion area of the supraspinatus can be expected (Figure 8).32 Whereas Lin et al26 incised the supraspinatus and made the inlet of the nail on the medial side of the greater tuberosity to reduce rotator cuff injury, we inserted the nail into the humeral head on the posterior aspect of the long head of the biceps brachii,33 because this area becomes the lateral side of the central axis of the humeral shaft, and the nail
600
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Figure 8 Photograph showing damage to supraspinatus insertion resulting from improper nail insertion.
13. 14.
can go through the humeral shaft if the inlet is made here (Figure 3).4 According to Lin and Hou,25 this nail insertion can reduce shoulder function by damaging the articular cartilage, but a loss of shoulder function as a result of the inlet of nailing was not observed. Third, although one of the disadvantages in intramedullary nailing is pain resulting from intraarticular protrusion of the nail, the impingement phenomenon of the nail and wear of the rotator cuff were prevented by countersinking the proximal end of the nail.9,10 Lin et al26 and Wachtl et al41 reported that forward flexion of the shoulder joint or Neer score showed a negative correlation with age on closed nailing. However, the methods performed by us showed no difference with regard to treatment outcomes by age when patients were divided into those aged younger than 65 years and those aged 65 years or greater (Table III). In summary, open intramedullary nailing accompanied by tension-band and locking sutures for proximal humeral fractures shows sufficient stability in older patients, and therefore, good postoperative shoulder function can be expected. REFERENCES
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37. Robinson CM, Bell KM, Court-Brown CM, McQueen MM. Locked nailing of humeral shaft fractures. Experience in Edinburgh over a two-year period. J Bone Joint Surg Br 1992;74:558-62. 38. Robinson CM, Christie J. The two-part proximal humeral fracture: a review of operative treatment using two techniques. Injury 1993;24:123-5. 39. Ruch DS, Glisson RR, Marr AW, Russell GB, Nunley JA. Fixation of three-part proximal humeral fractures: a biomechanical evaluation. J Orthop Trauma 2000;14:36-40. 40. Rush LV. The humerus. In: Rush LV, editor. Atlas of Rush pin technics. A system of fracture treatment. 2nd ed. Meridian (MS): Berivon; 1976. p. 112-33. 41. Wachtl SW, Marti CB, Hoogewoud HM, Jakob RP, Gautier E. Treatment of proximal humerus fracture using multiple intramedullary flexible nails. Arch Orthop Trauma Surg 2000;120:171-5. 42. Weinstein DM, Gomez MA, Hawkins RJ. Biomechanical comparison of tension band wiring versus plating in the fixation of three part fractures of the proximal humerus. Orthop Trans 1994; 18:3. 43. Wesely MS, Barenfield PA, Eisenstein AL. Rush pin intramedullary fixation for fractures of proximal humerus. J Trauma 1977;17:29-33. 44. Young TB, Wallace WA. Conservative treatment of fractures and fracture-dislocations of the upper end of the humerus. J Bone Joint Surg Br 1985;67:373-7.
To reduce complications and increase fixation after the internal fixation of proximal humeral fractures, interlocking intramedullary nailing and tension-band and locking sutures were used simultaneously, and their results are reviewed. Twenty-six consecutive patients who underwent open intramedullary nailing with tension-band and locking sutures for proximal humeral fractures were selected. The mean follow-up period was 39 months. With regard to the functional evaluation, the mean Neer score was 90 points and the mean American Shoulder and Elbow Surgeons score was 85. When patients were divided into those aged less than 65 years and those aged 65 years or greater and into those with 2-part fractures and those with 3-part fractures, postoperative pain, the American Shoulder and Elbow Surgeons score, and the Neer score showed no difference between the 2 groups. Open intramedullary nailing accompanied by tensionband and locking sutures for proximal humeral fractures shows sufficient fixation in older patients, and therefore, good postoperative shoulder function can be expected. (J Shoulder Elbow Surg 2006;15:594-601.)
P roximal humeral fractures account for 10% of all
fractures occurring in patients aged older than 60 years, and they comprise 45% of all humeral fractures.2 Although most proximal humeral fractures are treated conservatively,29,44 operative treatment is necessary when the fracture is markedly displaced or dislocated.8,15,23,27 Many methods are available for internal fixation of a From the aDepartment of Orthopaedic Surgery, Konkuk Medical School, Seoul, and bDepartment of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan. Supported by Konkuk University in 2005. Reprint requests: Jin-Young Park, MD, Shoulder, Elbow and Sports Service, Department of Orthopaedic Surgery, Konkuk University School of Medicine, 4-12, Hwangyang-Dong, Kwangjin-Gu, Seoul, 143-914, South Korea (E-mail: [email protected]). Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2006.01.001
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proximal humeral fracture, including wires,15,16,20,21 external fixation,5,24 Rush pins,40,43 metal plates,11,18,22 and intramedullary nails.26,33,39 Complications from these methods of fixation include fixation failure, impingement symptoms, pathology from the implants, and a decrease in shoulder function in displaced fractures in those patients with soft-tissue injury and severe osteoporosis.* We performed interlocking intramedullary nailing with placement of tension-band and locking sutures simultaneously for proximal humeral fractures to reduce the complications associated with internal fixation and to increase the fixation strength and then reviewed the results obtained. Our hypothesis is that tension-band and locking sutures with intramedullary nailing make early range of motion possible and give more stability compared with other techniques. MATERIALS AND METHODS In a retrospective study with a prospective protocol, 29 consecutive patients with proximal humeral fractures according to the classification of Neer29 underwent operative treatment between June 1998 and May 2001. Twenty-six cases with adequate follow-up form the basis for this study. The 3 cases with inadequate follow-up included 1 patient who died from stomach cancer metastasis, one who died after a cerebrovascular accident, and one who died from old age. The inclusion criteria for open intramedullary nailing combined with a tension-band and locking suture were 2- or 3-part fractures with severe comminution or osteoporosis and valgus-impacted 4-part fractures or fracture-dislocations (Figure 1). The exclusion criteria were as follows: patients who could be treated nonoperatively because their fractures lacked severe comminution, those who had a closed reduction and percutaneous pin fixation as a result of good bone quality of the proximal humerus as determined by bone mineral densitometry (dual-energy x-ray absorptiometry) (Norland XR-26 MARK II; Norland Corp., Fort Atkinson, WI), those with a 4-part fracture requiring humeral head replacement, those with a neglected fracturedislocation, and those with an isolated greater or lesser tuberosity fracture. For fracture classification, we used simple radiographs and 3-dimensional computed tomograms. The participants were 5 men and 21 women (Table I). *
References 1, 5, 8, 13, 15-17, 21, 22, 28, 30, 33, 34, 39, 41.
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Figure 1 Proximal humeral fracture combined with proximal humeral shaft fracture: Preoperative anteroposterior (A) and axillary lateral (B) views and postoperative anteroposterior (C) and axillary lateral (D) views at 2 years postoperatively.
Their mean age was 62 years (range, 27-79 years), and the mean follow-up period was 39 months (range, 24-59 months). The mechanisms of injury included motor vehicle accidents (2 cases) and pedestrian–motor vehicle accidents (7 cases). In addition, there were 13 cases of injury from a fall and 4 cases of a fall from a height. The mean time from injury to operation was 8 days (range, 0-27 days). A combined injury occurred in 14 of 26 cases. Combined neurologic injuries included radial nerve palsy (1 case) and brachial plexus injury (1 case). Anteroposterior bone mineral density from the second to fourth lumbar spine was measured in patients aged older than 50 years preoperatively (21 patients; mean age, 67 years). The mean bone mineral density was 0.74 g/cm2 (range, 0.57-1.02 g/cm2), and the mean T-score was ⫺2.6.
Operative technique The skin incision was performed via the deltopectoral approach with patients in the beach-chair position (Figure 2, A).15 To expose the humeral insertion of the supraspinatus and rotator interval, the leading edge of the coracoacromial ligament was removed.3 To reduce the incidence of avascular necrosis, only minimal removal of the periosteum necessary to visualize the fracture was performed. Direct manipulation of the fractured fragment was minimized by use of traction sutures on the rotator cuff attached to the greater or lesser tuberosity when a 3-part fracture was verified to be present (Figure 2, B). To reduce injury to the rotator cuff, the rotator interval was palpated and was incised parallel to the direction of the muscle fibers (Figure 3). The upper area of the humeral head was exposed by retracting the supraspinatus posteriorly and the long head of the biceps and the subscapularis anteriorly. In general, the center of the axis of the humeral shaft is located 8 mm
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toward the coronal plane and 3 mm posterior in the axial plane in relation to the center of the humeral head.4 This site is on the posterior side of the point at which the long head of the biceps comes out of the humeral head, and in this area, the point closer to the insertion site of the supraspinatus was chosen as the insertion site of the nail (Figure 3). In those cases of a surgical neck fracture, a guide wire was used to reduce the fracture and reaming was performed (Figure 2, C); the nail was then inserted into the humeral head, deeper than the articular cartilage, to prevent rotator cuff damage postoperatively. The Uniflex humeral nail (Biomet, Warsaw, IN) was used in 10 cases, and the Polarus nail (Acumed, Hillsboro, OR) was used in 16. The distal interlocking screw was inserted first. It was then determined whether the fractures of the greater or lesser tuberosity were reducible without tension (Figure 2, D). The 4 cases of a surgical neck fracture that showed a fracture line in the greater tuberosity underwent placement of locking sutures (horizontal intertuberosity sutures to assemble the greater and lesser tuberosity together) between the subscapularis and infraspinatus with No. 5 braided nonabsorbable sutures (Ethibond; Ethicon, Somerville, NJ) to increase the stability between the greater and lesser tuberosity (Figure 4). To prevent distraction and varus deformity between the humeral head and the shaft, tensionband sutures (vertical diaphyseal tuberosity sutures) were placed between the head of the distal interlocking screw and the supraspinatus, infraspinatus, and subscapularis by use of No. 2 or No. 5 braided nonabsorbable sutures (Ethibond) (Figure 5). Proximal locking screws were inserted to increase the rotational stability between the proximal humerus and the humeral shaft after superoinferior stability of the surgical neck fracture with the tension-band suture and stability between the greater and lesser tuberosity with the locking suture were obtained (Figure 3, E and F, and Figure 6). Autologous bone grafting was performed at the fracture site in 6 cases with 2- or 3-part fractures with severe comminution or osteoporosis and in 1 case with a 4-part fracture. Two cases of proximal humeral fracture combined with a shaft fracture also underwent bone grafting. After internal fixation, we confirmed whether the nail protruded above the humeral head. The incised rotator interval was sutured via a No. 2 nonabsorbable braided suture (Ethibond). One case with a massive rotator cuff tear underwent open repair. Acromioplasty was carried out in 9 patients who were identified to have a type II or III acromion with a spur, by abduction of the arm after internal fixation and palpation of the undersurface of acromion. No patient required a blood transfusion intraoperatively or postoperatively. In all patients, the proximal tip of the nail was located below the humeral head or at the same height; the nail was inserted on average 3 mm (range, 0-9 mm) deeper than the humeral head on postoperative radiography. The number of proximal interlocking screws averaged 3 (range, 2-4), whereas the number of distal interlocking screws averaged 2 (range, 1-2). Antegrade static interlocking nailing was carried out in all cases. All wounds were closed in layers with drainage, and the limb was put in an arm sling for 4 to 6 weeks. Systemic antibiotics with cefazolin and gentami-
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Table I Clinical data of patients with proximal humeral fractures treated by open intramedullary nailing with tension-band and locking sutures Range of motion No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Age (y)
Sex
Parts
AO/OTA Classification
Pain score
FE (°)
ER (°)
ER in 90° abduction (°)
IR
ASES score
Neer score
56 65 41 48 63 50 71 78 64 58 72 78 62 27 57 74 68 63 67 74 65 41 48 71 79 69
F F F M F M F F F M F F F M F F F F F F F F F F M F
2 2 2 3 3 2 3 3 3 3 3 3 3 3 2 3 2 3 3 3 3 3 3 4 3 2
B3 B2 B2 C1 C1 C3 C1 C3 B3 C1 C1 C1 B3 C3 B3 B2 B1 B1 C1 C2 B2 B2 C3 B2 B2 B3
1 3 1 2 1 1 2 3 0 1 1 1 2 1 0 0 0 0 0 0 1 1 2 1 0 6
140 120 150 140 90 150 140 100 150 150 150 120 150 150 150 140 140 150 150 150 150 150 160 140 140 90
60 30 70 40 30 70 0 40 50 30 50 30 50 50 60 30 50 70 45 40 50 50 70 60 45 10
80 50 70 70 30 90 40 70 80 70 60 50 70 80 70 80 75 80 70 60 60 80 80 80 70 30
T7 L2 T11 T12 L1 L2 L3 T11 T10 L5 T11 L2 L1 T10 T10 T11 T8 T11 T4 T8 T10 L5 T11 T12 L1 L5
90 72 92 77 83 88 73 68 87 95 92 77 80 85 98 92 92 93 100 98 92 88 87 82 88 40
95 76 98 85 90 92 80 75 98 88 92 86 92 95 99 97 96 99 98 99 98 89 92 86 92 45
FE, forward elevation; ER, external rotation; IR, internal rotation.
Figure 2 A, Exposure of proximal humeral fracture through deltopectoral approach. B, Traction sutures to greater or lesser tuberosity fragment were used for minimizing manipulation. C, Reaming of humeral head along guide wire after reduction between head and shaft fragment. D, Checking of fragment reduction by use of traction sutures. E, Operative finding in external rotation of humerus after internal fixation with intramedullary nailing and tensionband suture. F, Operative finding in internal rotation of humerus.
Figure 3 Exposure of humeral head through rotator interval (between supraspinatus and subscapularis) in surgical neck fracture and 3-part fracture. An incision was made at the anterior leading edge of the supraspinatus. The inlet of the intramedullary nail on the humeral head is situated at the medial side of the insertion of the supraspinatus and the posterior side of the long head of the biceps brachii.
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Figure 4 Locking sutures (No. 5 nonabsorbable braided sutures) were placed between the greater tuberosity and lesser tuberosity to increase the stability of the humeral head fragments.
cin were used for 3 to 7 days based on the status of wound healing.
Rehabilitation Postoperative abduction bracing or cast immobilization was not used. On the first day after the operation, pendulum exercises and passive forward elevation exercises of the shoulder joint were started. On the second day, a pulley exercise was performed, and in the fifth week after surgery, patients started external rotation exercises with a stick. Radiologic examinations were carried out at 6 and 10 weeks and 4 and 6 months after surgery, and active range of motion was allowed if bony union was identified in the sixth week or tenth week after operation.
Evaluations A visual analog pain evaluation with a scale ranging from 0 to 10 was carried out at the final follow-up. The functional evaluation of the shoulder joint used a 100-point score according to the evaluation of Neer29 and the evaluation of the American Shoulder and Elbow Surgeons (ASES)35 at the final follow-up. The ASES score was classified as excellent (91-100), good (81-90), fair (71-80), or poor (⬍70); of these, excellent and good scores were defined as satisfactory. A physician’s assistant determined the range of motion by measuring forward elevation of the shoulder, external rotation with the patient’s arm at the side, external rotation in 90° abduction, and internal rotation. All patients, except one, were followed up at monthly intervals until the fracture consolidation was apparent on X-ray and then reviewed at 3 monthly intervals for this study to record the functional
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Figure 5 Tension-band sutures were placed between the rotator cuff and distal interlocking screw to increase the stability of the surgical neck fracture by use of No. 5 nonabsorbable braided sutures.
outcome. If the final follow-up was not possible, a telephone survey was conducted. For statistical analysis, the Student t test was used for patients’ ages and range of motion by use of SPSS software, version 11.0 (SPSS, Chicago, IL), and the MannWhitney U test was used for pain, ASES scores, and Neer scores. Tests were considered statistically significant at P ⬍ .05.
RESULTS Bony union was obtained in 25 of 26 cases on final follow-up. The time to union averaged 8.7 weeks (range, 7-12 weeks). The mean operation time and blood loss were 2.1 hours (range, 1.5-3.2 hours) and 230 mL (range, 120-320 mL), respectively. The mean pain score was 1 point (range, 0-6). The mean Neer score was 90 points (range, 45-99) and was considered excellent in 18 cases, good in 5, and unsatisfactory or a failure in 3. The mean postoperative ASES score was 85 points (range, 40-100) and was considered excellent in 11 cases, good in 9, fair in 4, and poor in 2. The patient whose case was considered a failure by the Neer evaluation and who had a poor result by the ASES evaluation had a fracture-dislocation accompanied by a 2-part surgical neck fracture and a large Hill-Sachs lesion. This patient was admitted to our hospital for a loss of reduction at the fracture site 1 month after closed reduction and percutaneous pin fixation. Although open reduction–internal fixation was performed, a Bankart lesion repair was carried out because of redislocation. In the fourth month of
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Figure 6 Open intramedullary nailing with tension-band and locking suture resembling hot air balloon. The interlocking nail for rotational stability is the hot air, the locking sutures are the horizontal load tapes, and the tension-band sutures are the vertical load tapes. The load tapes share the stress about the explosive power of the balloon.
follow-up, humeral head replacement was performed because of the development of avascular necrosis. The patient who was considered to have an unsatisfactory result by the Neer evaluation and a poor result by the ASES evaluation had a 3-part fracturedislocation in the greater tuberosity and surgical neck. In this patient, postoperative nonunion and upward protrusion of the nail occurred. A humeral head replacement was performed for nonunion after 14 months. The patient whose case was considered a failure by the Neer evaluation and who had a fair result by the ASES evaluation was admitted for a loss of reduction after closed reduction with percutaneous pin fixation at another hospital. Combined injuries included an ipsilateral ankle fracture and a fracture in the thoracic spine. Although open reduction, internal fixation, bone grafting, and acromioplasty were car-
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ried out, we could not obtain an accurate reduction because of the delay in surgery. Postoperative angulation was 40° at the fracture site. The patient had muscle weakness and motion limitation postoperatively. Three cases had a satisfactory result by the Neer evaluation and a fair result by the ASES evaluation: two with 3-part fractures and combined extremity injuries and one with a surgical neck fracture and a cardiovascular condition. All had mild pain and limitation of range of motion. When patients were divided into those with 2-part fractures and those with 3-part fractures, postoperative pain, ASES, and Neer scores showed no significant differences (Table II), and when they were divided into those aged younger than 65 years and those aged 65 years or greater, postoperative pain, ASES, and Neer scores also showed no significant difference (Table III). Mean forward elevation was 139° (range, 90°160°) (7° decrease compared with contralateral shoulder), mean external rotation was 45° (range, 0°-70°) (11° decrease compared with contralateral side), mean external rotation at 90° abduction was 66° (range, 30°-90°) (5° decrease compared with contralateral side), and internal rotation was to the spinous process of the T12 vertebra (range, spinous process of T4 to L5) (decrease of 3 vertebral heights compared with contralateral side). Postoperative complications included nonunion (1 case), avascular necrosis of the humeral head (1 case), and protrusion of the proximal interlocking screw (1 case). There were no implant failures or superficial or deep infections. Two cases showed more than 20° of anterior angulation of the surgical neck (20° and 40°), and both patients had an unsatisfactory Neer score. More than 5 mm of malunion of the greater tuberosity was seen in 2 cases of malunion superiorly (5 mm and 8 mm) and in 2 cases of malunion inferiorly (5 mm and 8 mm). However, the treatment outcomes of these 4 cases were better than good with regard to the Neer and ASES scores (Figure 7). There were 3 cases of revision operations: 2 had humeral head replacements for avascular necrosis of the humeral head and nonunion and 1 had lysis of adhesions for a surgical neck fracture combined with a myositis ossificans after head injury. DISCUSSION Different forms of intramedullary nailing have been used for humeral fractures (eg, Rush rod, Enders nail, and Seidel nail) since Christensen7 used the Küntscher nail in 1976, and an interlocking nail has recently been introduced.14,36,40 The interlocking nail has advantages in that it can provide rotational
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Table II Operative results of proximal humeral fractures according to fracture patterns
Table III Operative results of proximal humeral fractures according to age at injury
Fracture pattern 2 Parts
>2 Parts
No. of cases 11 15 Male/female 2/9 3/12 Fracture pattern (No. of cases) 2 Parts 8 0 3 Parts 0 12 4 Parts 0 1 fracture-dislocation 1 1 Combined with shaft fracture 2 1 Pain scale (visual analog scale from 0 to 10) [mean ⫾ SD (range)] 1 ⫾ 2 (0–6) 1 ⫾ 1 (0–3) ASES score [mean ⫾ SD (range)] 84 ⫾ 17 (40–98) 86 ⫾ 8 (68–100) Neer score [mean ⫾ SD (range)] 88 ⫾ 16 (45–99) 91 ⫾ 7 (75–99)
stability of the fracture site after internal fixation, it can prevent superior migration of the proximal humerus, and it has a low possibility of nail protrusion.1,19,33 According to reported studies,1,33 in cases of surgical neck fractures and 3-part fractures of the proximal humerus, intramedullary nailing yields satisfactory results in more than 80%. However, Chapman et al6 reported that the use of a nail reduced shoulder function. The causes of this reduction were indicated to be impingement of the nail in the subacromial space,9 superior protrusion of the nail,10,37 protrusion of the screw,10,37 and rotator cuff injury.37 Fixation by use of a Rush rod and tension-band wiring38,40 or by use of the modified Enders nail and tension-band wiring have the problem of reduced shoulder function as a result of superior migration of the pin3 and nail.38,41,43 Although tension-band wiring has the problem of extending the posteromedial aspect of the fracture gap and cutting through it, Hawkins and Angelo15 improved this problem by using 2 pieces of tension-band wiring. As reported by Ruch et al39 and Weinstein et al,42 interlocking intramedullary nailing could increase banding and torsional strength. This was carried out in parallel with tension-band wiring, which was useful for proximal humeral fractures with osteoporosis. With this treatment method, a low rate of complications, including 1 case of protrusion of the proximal interlocking screw, 1 case of nonunion, and 1 case of avascular necrosis, was found, in addition to 6 cases of malunion, which were a result of a technical error during early series using the operation. Fixation by use of nonabsorbable heavy sutures yielded good results even though rotational instability occurred sometimes.12,31 Therefore, we used a com-
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Age <65 y
>65 y
No. of cases 13 13 Male/female 4/9 1/12 Fracture pattern (No. of cases) 2 Parts 4 4 3 Parts 6 6 4 Parts 0 1 Fracture-dislocation 0 2 Combined with shaft fracture 3 0 Pain scale (visual analog scale from 0 to 10) [mean ⫾ SD (range)] 1 ⫾ 1 (0–2) 1 ⫾ 2 (0–6) ASES score [mean ⫾ SD (range)] 88 ⫾ 6 (77–98) 82 ⫾ 16 (40–100) Neer score [mean ⫾ SD (range)] 91 ⫾ 6 (77–99) 83 ⫾ 14 (45–99)
Figure 7 Postoperative radiograph showing inferior malunion of greater tuberosity.
bined technique with interlocking intramedullary nailing and heavy sutures. We carried out the following operative techniques to minimize the loss of shoulder function that may occur after internal fixation by use of a nail: First, the humeral head was exposed through the rotator interval to reduce the loss that may occur by the incision of the rotator cuff. Second, if a nail with an 11-mm proximal diameter is inserted into the rotator cuff when the insertion area of the supraspinatus is considered to be 374 mm2, a 25% loss of insertion area of the supraspinatus can be expected (Figure 8).32 Whereas Lin et al26 incised the supraspinatus and made the inlet of the nail on the medial side of the greater tuberosity to reduce rotator cuff injury, we inserted the nail into the humeral head on the posterior aspect of the long head of the biceps brachii,33 because this area becomes the lateral side of the central axis of the humeral shaft, and the nail
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Figure 8 Photograph showing damage to supraspinatus insertion resulting from improper nail insertion.
13. 14.
can go through the humeral shaft if the inlet is made here (Figure 3).4 According to Lin and Hou,25 this nail insertion can reduce shoulder function by damaging the articular cartilage, but a loss of shoulder function as a result of the inlet of nailing was not observed. Third, although one of the disadvantages in intramedullary nailing is pain resulting from intraarticular protrusion of the nail, the impingement phenomenon of the nail and wear of the rotator cuff were prevented by countersinking the proximal end of the nail.9,10 Lin et al26 and Wachtl et al41 reported that forward flexion of the shoulder joint or Neer score showed a negative correlation with age on closed nailing. However, the methods performed by us showed no difference with regard to treatment outcomes by age when patients were divided into those aged younger than 65 years and those aged 65 years or greater (Table III). In summary, open intramedullary nailing accompanied by tension-band and locking sutures for proximal humeral fractures shows sufficient stability in older patients, and therefore, good postoperative shoulder function can be expected. REFERENCES
1. Adedapo AO, Ikpeme JO. The results of internal fixation of threeand four-part proximal humeral fractures with the Polarus nail. Injury 2001;32:115-21. 2. Baron JA, Karagas M, Barrett J, Kniffin W, Malenka D, Mayor M, et al. Basic epidemiology of fractures of the upper and lower limb
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