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Surgical treatment for proximal humeral fracture in elderly patients with emphasis on the use of intramedullary strut allografts

Cheng-Huan Penga, Wen-Tien Wua, b, Tzai-Chiu Yua, b, Li-Chun Chenc, Shih-Hsiang Hsua, b, Sai-Tung Kwonga, Ting-Kuo Yaoa, Kun-Chi Wua, b, Po-Chou Shaoa, Jen-Hung Wangd, Ing-Ho Chena, b

a Department of Orthopedics, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
b School of Medicine, Tzu Chi University, Hualien, Taiwan
c Department of Physical Medicine and Rehabilitation, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
d Department of Medical Research, Buddhist Tzu Chi General Hospital, Hualien, Taiwan

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Abstract
Objective

To review the results of proximal humeral fracture in elderly patients receiving open reduction and internal fixation (ORIF), and to investigate whether use of intramedullary strut allografts leads to better outcomes.

Methods

Retrospective review of radiographs, charts, and surgical records of 90 patients, age 65 years and older, followed up for a minimum of 12 months after buttress plate fixation of a proximal humeral fracture from January 2001 to March 2011. The fractures were reduced with or without insertion of an intramedullary strut allograft during the operation. We analyzed overall results, fracture union status, and varus collapse (by determining the change in the neck-shaft angle and humeral head height) by radiography at 5 different time points: immediately and 1, 3, 6, and, 12 months postoperative.

Results

The 90 patients enrolled in the study included 24 men and 66 women. An intramedullary strut allograft was applied in 55 patients (BG group), and not applied in the remaining 35 patients (non-BG group). Overall favorable union was achieved in 72.2 % (65 of 90) of patients, with malunion in 20% (18 of 90) and nonunion in 7.8% (7 of 90). There were no significant differences between patients with satisfactory and unsatisfactory outcomes in terms of age or gender. The percentage of satisfactory outcomes was clearly higher in the BG group (92.73% vs. 40%, p < 0.001). Ironically, better outcomes were obtained in the severe group (Neer 3-, and 4-part fractures) than the minor group (Neer 2-part fractures) (82.98% vs. 60.47% p = 0.017). The degrees of loss of reduction with the use or nonuse of intramedullary strut allografts in the favorable union and malunion groups were compared. The amount of loss of reduction in the neck-shaft angle was significantly lower in the BG group than the non-BG group (2.43° vs. 11.11°, p < 0.001). The amount of loss of reduction in humeral head collapse was significantly lower in the BG group than the non-BG group (2.05 mm vs. 6.01 mm, p < 0.001).

Conclusions

Complications after treating proximal humeral fracture in the elderly are frequently encountered because of poor bone quality. When fixing the fracture with plates, adjuvant use of intramedullary strut allograft can significantly enhance the result and reduce the incidence of malunion, nonunion and varus collapse.

Keywords
Humeral head height; Intramedullary strut allograft; Neck-shaft angle; Proximal humeral fracture; Varus collapse


 

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