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Die mediale Abstützung bei der Frakturversorgung am proximalen Humerus durch eine retrograde Nagelosteosynthese – biomechanische und klinische Aspekte

Medial support for treatment of fractures of the proximal humerus by retrograde nail osteosynthesis: biomechanical and clinical aspects

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Zusammenfassung

Bei Frakturen des proximalen Humerus stellt eine mediale metaphysäre Trümmerzone ein Problem dar, weil diese Frakturen dazu neigen, trotz Osteosynthese, sekundär in eine Varusfehlstellung abzurutschen. In der Literatur wurde die Bedeutung von inferomedialen Schrauben für die mediale Stabilisierung erkannt. Diese gilt heute als wesentliche Voraussetzung für eine dauerhafte stabile Versorgung. Trotz dieser Abstützung kann es zu einer sekundären Varusfehlstellung kommen. Von verschiedenen Autoren wurden enostale allogene Knochentransplantate, die zusätzlich zu einer winkelstabilen Plattenosteosynthese implantiert wurden, als geeignete Augmentation beschrieben. Dieses Verfahren ist allerdings in der Anwendung deutlich limitiert und scheint für einen flächendeckenden Einsatz nicht geeignet. Ein neu entwickelter, retrograder Nagel erfüllt aus theoretischer Sicht sämtliche Kriterien für eine stabile Osteosynthese proximaler Humerusfrakturen, inkl. der medialen Abstützung.

In der vorliegenden Arbeit werden die Problematik der medialen Instabilität proximaler Humerusfrakturen dargelegt und biomechanische und erste klinische Ergebnisse mit dem retrograden proximalen Humerusnagel beschrieben.

Abstract

In proximal humerus fractures with medially comminuted metaphyses, secondary varus malalignment is one of the major difficulties for the trauma surgeon. Recent studies stressed the importance of inferomedial screws for medial support. These screws were found to be one of the most influencing factors for stable osteosynthesis. Despite proper placement of these screws secondary varus dislocation can still happen. Some authors suggested enostal allografts in addition to locking plates for medial support; however, for many reasons this method is and will remain an exception. A recently developed retrograde nail for the proximal humerus fulfills, from a theoretical point of view, all aspects for a sufficient fixation of proximal humerus fractures, including medial support. This article discusses the need for and difficulties of a sufficient inferomedial support in proximal humerus fractures and discuss the biomechanical findings and first clinical experiences with this new device.

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Literatur

  1. Chudik S (2003) Fixed-angle plate fixation in simulated fractures of the proximal humerus: a biomechanical study of a new device. J Shoulder Elbow Surg 12(6):578–588

    Article  PubMed  Google Scholar 

  2. Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF (2010) Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 19(4):489–494

    Article  PubMed  Google Scholar 

  3. Dietrich M, Meier C, Lattmann T, Zingg U, Gruninger P, Platz A (2008) Complex fracture of the proximal humerus in the elderly. Locking plate osteosynthesis vs hemiarthroplasty. Chirurg 79(3):231–240

    Article  PubMed  CAS  Google Scholar 

  4. Dietz SO, Hartmann F, Schwarz T, Nowak TE, Enders A, Kuhn S et al (2011) Retrograde nailing versus locking plate osteosynthesis of proximal humeral fractures: a biomechanical study. J Shoulder Elbow Surg 21(5):618–624

    Article  PubMed  Google Scholar 

  5. Duralde XA, Leddy LR (2010) The results of ORIF of displaced unstable proximal humeral fractures using a locking plate. J Shoulder Elbow Surg 19(4):480–488

    Article  PubMed  Google Scholar 

  6. Edwards SL, Wilson NA, Zhang LQ, Flores S, Merk BR (2006) Two-part surgical neck fractures of the proximal part of the humerus. A biomechanical evaluation of two fixation techniques. J Bone Joint Surg 88(10):2258–2264

    Article  PubMed  Google Scholar 

  7. Foruria AM, Carrascal MT, Revilla C, Munuera L, Sanchez-Sotelo J (2010) Proximal humerus fracture rotational stability after fixation using a locking plate or a fixed-angle locked nail: the role of implant stiffness. Clin Biomech (Bristol, Avon) 25(4):307–311

    Article  Google Scholar 

  8. Füchtmeier B, May R, Hente R, Maghsudi M, Völk M, Hammer J et al (2007) Proximal humerus fractures: a comparative biomechanical analysis of intra and extramedullary implants. Arch Orthop Trauma Surg 127(6):441–447

    Article  PubMed  Google Scholar 

  9. Gardner MJ, Boraiah S, Helfet DL, Lorich DG (2008) Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 22(3):195–200

    Article  PubMed  Google Scholar 

  10. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG (2007) The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 21(3):185–191

    Article  PubMed  Google Scholar 

  11. Helwig P, Bahrs C, Epple B, Oehm J, Eingartner C, Weise K (2009) Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus? A prospective series of 87 patients. Acta Orthop 80(1):92–96

    Article  PubMed  Google Scholar 

  12. Hepp P, Lill H, Bail H, Korner J, Niederhagen M, Haas NP et al (2003) Where should implants be anchored in the humeral head? Clin Orthop Relat Res Oct(415):139–147

    Article  Google Scholar 

  13. Hertel R, Hempfing A, Stiehler M, Leunig M (2004) Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 13(4):427–433

    Article  PubMed  CAS  Google Scholar 

  14. Hessmann MH, Hansen WSM, Krummenauer F, Pol TF, Rommens M (2005) Locked plate fixation and intramedullary nailing for proximal humerus fractures: a biomechanical evaluation. J Trauma 58(6):1194–1201

    Article  PubMed  Google Scholar 

  15. Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG (2010) Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am 92(4):943–948

    Article  PubMed  Google Scholar 

  16. Lescheid J, Zdero R, Shah S, Kuzyk PR, Schemitsch EH (2010) The biomechanics of locked plating for repairing proximal humerus fractures with or without medial cortical support. J Trauma 69(5):1235–1242

    Article  PubMed  Google Scholar 

  17. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG (2000) Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg 9(5):423–426

    Article  PubMed  Google Scholar 

  18. Lill H, Hepp P, Rose T, Konig K, Josten C (2004) The angle stable locking-proximal-humerus-plate (LPHP) for proximal humeral fractures using a small anterior-lateral-deltoid-splitting-approach—technique and first results. Zentralbl Chir 129(1):43–48

    Article  PubMed  CAS  Google Scholar 

  19. Lippuner K, Popp AW, Schwab P, Gitlin M, Schaufler T, Senn C et al (2010) Fracture hospitalizations between years 2000 and 2007 in Switzerland: a trend analysis. Osteoporosis Int 22(9):2487–2497

    Article  Google Scholar 

  20. Marti A, Fankhauser C, Frenk A, Cordey J, Gasser B (2001) Biomechanical evaluation of the less invasive stabilization system for the internal fixation of distal femur fractures. J Orthop Trauma 15(7):482–487

    Article  PubMed  CAS  Google Scholar 

  21. Matziolis D, Kaeaeb M, Zandi SS, Perka C, Greiner S (2010) Surgical treatment of two-part fractures of the proximal humerus: comparison of fixed-angle plate osteosynthesis and zifko nails. Injury 41(10):1041–1046

    Article  PubMed  Google Scholar 

  22. Meyer C, Alt V, Hassanin H, Heiss C, Stahl JP, Giebel G et al (2005) The arteries of the humeral head and their relevance in fracture treatment. Surg Radiol Anat 27(3):232–237

    Article  PubMed  CAS  Google Scholar 

  23. Olerud P, Ahrengart L, Söderqvist A, Saving J, Tidermark J (2010) Quality of life and functional outcome after a 2-part proximal humeral fracture: a prospective cohort study on 50 patients treated with a locking plate. J Shoulder Elbow Surg 19(6):814–822

    Article  PubMed  Google Scholar 

  24. Osterhoff G, Baumgartner D, Favre P, Wanner GA, Gerber H, Simmen HP et al (2011) Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. J Shoulder Elbow Surg 20(5):740–746

    Article  PubMed  Google Scholar 

  25. Park JY, Kim JH, Lhee SH, Lee SJ (2011) The importance of inferomedial support in the hot air balloon technique for treatment of 3-part proximal humeral fractures. J Shoulder Elbow Surg 21(9):1152–1159

    Article  PubMed  Google Scholar 

  26. Robinson CM, Amin AK, Godley KC, Murray IR, White TO (2011) Modern perspectives of open reduction and plate fixation of proximal humerus fractures. J Orthop Trauma 25(10):618–629

    Article  PubMed  Google Scholar 

  27. Roderer G, Erhardt J, Graf M, Kinzl L, Gebhard F (2010) Clinical results for minimally invasive locked plating of proximal humerus fractures. J Orthop Trauma 24(7):400–406

    Article  PubMed  Google Scholar 

  28. Roderer G, Gebhard F, Krischak G, Wilke HJ, Claes L (2010) Biomechanical in vitro assessment of fixed angle plating using a new concept of locking for the treatment of osteoporotic proximal humerus fractures. Int Orthop 35(4):535–541

    Article  PubMed  Google Scholar 

  29. Sanders BS, Bullington AB, McGillivary GR, Hutton WC (2007) Biomechanical evaluation of locked plating in proximal humeral fractures. J Shoulder Elbow Surg 16(2):229–234

    Article  PubMed  Google Scholar 

  30. Saran N, Bergeron SG, Benoit B, Reindl R, Harvey EJ, Berry GK (2010) Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide. Injury 41(10):1037–1040

    Article  PubMed  Google Scholar 

  31. Siffri PC, Peindl RD, Coley ER, Norton J, Connor PM, Kellam JF (2006) Biomechanical analysis of blade plate versus locking plate fixation for a proximal humerus fracture: comparison using cadaveric and synthetic humeri. J Orthop Trauma 20(8):547–554

    Article  PubMed  Google Scholar 

  32. Sproul RC, Iyengar JJ, Devcic Z, Feeley BT (2010) A systematic review of locking plate fixation of proximal humerus fractures. Injury 42(4):408–413

    Article  PubMed  Google Scholar 

  33. Zhang L, Zheng J, Wang W, Lin G, Huang Y, Edem Prince GA et al (2011) The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study. Int Orthop 35(11):1655–1661

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Zentrum für muskuloskeletale Chirurgie Klinik und Poliklinik für Unfallchirurgie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland

    S. O. Dietz, R. Küchle, A. Enders, F. Hartmann, T. E. Nowak, A. Hofmann & P. M. Rommens

  2. Abteilung für Allgemein-und Unfallchirurgie, St. Josefs-Hospital Wiesbaden, Wiesbaden, Deutschland

    D. Sohlbach & F. E. Isemer

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  1. S. O. Dietz
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  2. D. Sohlbach
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  3. R. Küchle
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  4. A. Enders
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  5. F. Hartmann
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  6. T. E. Nowak
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  7. A. Hofmann
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  8. F. E. Isemer
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  9. P. M. Rommens
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Corresponding author

Correspondence to S. O. Dietz.

Additional information

Dietz SO und Sohlbach D haben gleichberechtigt zur Erstellung des Artikels beigetragen.

Einzelne klinische Fälle sind Bestandteil der Dissertationsarbeit von Sohlbach D. Teile der Ergebnisse wurden bereits publiziert (4).

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Dietz, S., Sohlbach, D., Küchle, R. et al. Die mediale Abstützung bei der Frakturversorgung am proximalen Humerus durch eine retrograde Nagelosteosynthese – biomechanische und klinische Aspekte. Obere Extremität 7, 221–227 (2012). https://doi.org/10.1007/s11678-012-0184-y

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  • DOI: https://doi.org/10.1007/s11678-012-0184-y

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