creative Commons Non Commercial CC BY-NC : This article is distributed under the terms of the creative Commons Attribution-NonCommercial 4.0 License ( hypertext transfer protocol : //creativecommons.org/licenses/by-nc/4.0/ ) which permits non-commercial use, replica and distribution of the work without far permission provided the original oeuvre is attributed as specified on the SAGE and Open Access pages ( hypertext transfer protocol : //us.sagepub.com/en-us/nam/open-access-at-sage ). Twenty patients, including eight with Neer bipartite and 12 with three-part fractures, were followed-up, with a base time of 12.3 months. All patients sustained fractures that healed without re-varus. During the last follow-up, the shoulder serve of the patients had recovered well, with a mean VAS pain score of 1.4, a mean CSS of 83.1, a mean DASH score of 80.8, a beggarly ASES score of 84.0 and a satisfactory ROM. In one patient, the proximal lock screw came forbidden and was removed via a second surgery. In holocene years, the use of intramedullary nails for the treatment of proximal humeral fractures has gradually increased and the overall clinical result has been dependable. 10 – 12 however, whether the use of a engage intramedullary nail entirely is suitable for initial varus proximal humeral fractures has not been reported in the literature. thus, the current prospective fender learn aimed to evaluate the feasibility of using a lock intramedullary collar alone for the discussion of initial varus proximal humeral fractures. initial varus proximal humeral fault refers to proximal humerus fracture with varus translation of the humeral head and it is characterized by the comminution of the median lens cortex. This type of fracture is susceptible to re-varus shift due to the miss of median support after decrease. furthermore, individuals with initial varus proximal humeral fractures have a higher risk of re-varus translation, complications, screw penetration and reoperation than those with valgus fractures. 6 The lock plate system, including the PHILOS® plate, is hush the independent inner plant used for the obsession of this fracture. however, complications, including the varus displacement of humerus promontory, normally occur after elementary lateral locking plate fixation. 7 The methods used to prevent varus shift of the humeral head include the use of humeral prison guard, allogeneic fibula intramedullary implantation, double-plate obsession and shortening of the humeral beam with internal displacement. 8, 9 These methods have disadvantages, such as immune chemical reaction, infections and surgical injury, and they should be used with caution in specific patients. 8, 9

proximal humeral fractures account for 4–5 % of all types of fracture ; 1 and their incidence ranks second after hep and distal radius fractures among aged patients. 2 – 4 With the aging population, the incidence of this type of fracture may continue to rise and the hazard for surgical discussion may gradually increase. A former study reported that between 1990 and 2010, the incidence of proximal humeral fractures in patients aged over 65 years increased by 28 %, and the rate of surgical treatment increased by more than 40 %. 5 Complications correlated with fracture healing, such as varus deformity bring around ( neck-shaft fish < 110° ), cram nonunion, delayed healing, infection, bankruptcy of inner fixation, humeral headway ischemic necrosis, rotator manacle injury and shoulder shock syndrome, were recorded. To measure the neck-shaft angle, a pipeline from superior to the deficient borders of articular surface was created. A second line vertical to the first gear lineage was created, which went through the center of the humeral head. The neck-shaft fish was defined as the angle created by this credit line and the line bisecting the humeral shot. When the bone fracture cable was disappeared on radiography and the clinical physical examinations showed no tenderness, percussion section pain, or abnormal bowel movement, the fracture bone was considered to be healing. After the operating room, the patients used an abduction pillow sling for 6 weeks and passive voice gesture exercises were performed immediately. Full active and active-assisted motion exercises were initiated 4–6 weeks after operating room. then, the patients were besides encouraged to undergo reclamation train with the guidance of rehabilitation physicians. After the surgery, the patients were followed-up at the outpatient department at 2, 6 and 12 weeks and every 3 months thereafter. Radiography was performed to evaluate fracture healing and to measure the neck-shaft fish. A ocular analogue scale ( VAS ) annoyance score, constant Shoulder Score ( CSS ), Disabilities of the Arm, Shoulder and Hand ( DASH ) score, American Shoulder and Elbow Surgeons ( ASES ) score and shoulder range of motion ( ROM ) were recorded to evaluate postoperative shoulder serve. A senior surgeon ( H.S. ) performed the procedure within 2 weeks after sustaining the fractures. The patients were placed in a beach chair side. then, a 5-cm incision was created at the anterior-lateral acromion ( ). In cases of three-part fractures with greater tuberosity translation, an appropriate elongation of the distal incision was made to facilitate intraoperative reduction of greater tuberosity while protecting the axillary heart. The deltoid was split to expose the proximal humerus and rotator cuff. For the bipartite fractures, 2.0-mm Kirschner wires were drilled into the humeral head. Using the Joy-stick proficiency, the fracture was reduced under traction to correct the humeral head varus deformity. The lead needle of the intramedullary nail down was drilled in rotator interval and intraoperative radiography was performed to confirm the right steer of humeral question entry. This point was selected as the intersection of the axis of the humeral quill with the humeral head, which is equivalent to a medial of 1.0 curium, at the junction of the humeral head and greater tuberosity. A hollow reamer was used to enlarge the hole under the steering of the guidebook phonograph needle. then, a TRIGEN ◊ straight interlocking intramedullary smash with a proximal diameter of 8.0 mm and distal diameter of 7.0 millimeter ( TRIGEN ◊ Humeral Nail ; Smith & Nephew, Cordova, TN, USA ) was inserted. The place of the intramedullary breeze through and reduction of fractures were confirmed via intraoperative radiography ( ). Three proximal and two distal locking screws were inserted. For the three-part fractures with greater tuberosity translation, after inserting the intramedullary collar, the greater tuberosity shard was reduced and maintained with the reduction forceps ; then, the proximal lock in screws were inserted ( ). This study was conducted in accord with the guidelines of the Declaration of Helsinki for Human Research. As the techniques used in this study were everyday, the prerequisite for ethical approval was waived. Written informed consent was obtained from all participants and their rights to privacy were preserved. This prospective pilot study enrolled back-to-back patients with confirmed initial varus proximal humeral fractures, based on their checkup history and preoperative shoulder radiography and computed tomography scan results, from the Department of Orthopaedic Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China between June 2015 and December 2017. The inclusion criteria were as follows : ( i ) patients with proximal humeral two-/three-part fractures ; ( two ) patients with varus displacement of the humeral head ( neck-shaft angle < 110° ). The exclusion criteria were as follows : patients with ( one ) proximal humeral fracture with humeral lead burst ; ( two ) combined with shoulder dislocation ; ( three ) open or pathological fractures ; ( intravenous feeding ) combined with rotator handcuff injury ; ( volt ) signs of infection at the injure shoulder. In terms of postoperative complications, the proximal engage prison guard came out and was removed via a second surgery after fault heal in one patient. none of the patients presented with complications, such as humeral head varus disfigurement, bone nonunion, delayed heal, infection, bankruptcy of internal fixation and ischemic necrosis of the humeral question. A distinctive case is shown in.

According to the radiography results obtained during follow-up, all patients presented with anatomic decrease and fractures that healed with a mean ± SD time of 2.47 ± 0.41 months. The beggarly ± SD postoperative immediate neck-shaft angle was 134.2° ± 7.4° ( range 118°–145° ). During the last follow-up, the beggarly ± SD neck-shaft angle was 133.7° ± 7.2° ( range 118°–145° ). furthermore, the shoulder function of the patients recovered well, with a mean ± SD VAS pain seduce of 1.4 ± 0.8 ( range 0–3 ), a entail ± SD CSS of 83.1 ± 4.8 ( range 74–93 ), a hateful ± SD DASH score of 80.8 ± 4.4 ( range 73–88 ) and a base ± SD ASES of 84.0 ± 3.4 ( range 78–94 ). This prospective fender analyze enrolled 21 patients diagnosed with initial varus proximal humeral fracture. Of the 21 patients, 20, including eight with Neer bipartite and 12 with three-part fractures, were followed-up with a think of duration of 12.3 months ( range 8–15 months ). One patient was lost to follow-up. There were seven men and 13 women. The mean ± SD old age of the participants was 64.2 ± 4.78 years ( range 54–75 years ) .

Discussion

A proximal humerus fracture of the varus type is characterized by the comminution of the median cortex of the proximal humerus after the displacement of the humerus head. The want for surgical treatment may gradually increase ascribable to the aging population. The locking plate system is still the main internal implant used for the arrested development of this type of fracture and some researchers reported the utilization of a modify plate for the management of proximal humerus fracture and even proximal humeral aseptic nonunion. 7, 13, 14 however, varus displacement of the humerus heading occasionally occurs. therefore, attention must be paid to re-varus translation after reduction and fixation, and postoperative re-varus displacement is challenging to prevent. The lack of effective medial support after decrease and the effect of the rotator cuff on the median side might have caused re-varus after surgery, thereby resulting in a series of complications, including internal fixation failure. 15, 16 In a omen analysis of proximal humeral three-/four-part fractures treated with locking plates, the incidence of complications in the varus fracture group was importantly higher than that in the valgus fracture group ( 79 % versus 19 % ). 17 Regarding this problem, respective researchers have proposed unlike methods for preventing re-varus of the humeral head. For model, a former study showed the importance of using an oblique lock cheat in preventing re-varus of the humeral head and argued that placing an devious locked cheat in the inferomedial area of the proximal shard could achieve more stable medial column documentation and could obtain a better reduction care. 18 Some studies have shown that if the medial cortex is effectively supported, anatomical reference decrease can be achieved and maintained, and the use of an oblique locked screw in the inferomedial region may prevent re-varus. 19, 20 however, this technique is extremely challenging for varus fractures often accompanied by medial comminution. To restore an effective medial support, the use of allogeneic fibula implants to restore medial corroborate was proposed. 21 several subsequent studies have shown the efficacy of this proficiency. 22 – 26 however, allogeneic fibula implantation undoubtedly increases the risk of surgical trauma and infection. furthermore, some researchers have proposed the use of double-plate technology to prevent varus of the humeral head and biomechanical experiments have besides validated that the double-plate engineering can provide a more stable medial obsession. 27, 28 however, placing a plate on the median humerus may damage the front tooth humeral artery, resulting in necrosis of the humeral head. 27, 28 In recent years, with the development of proximal humeral intramedullary nails, the use of intramedullary nails for proximal humeral fractures has gradually increased and has achieved good remedy outcomes. 10, 28 – 30 A former study used heterosexual interlocking intramedullary nails in 26 patients with proximal humeral fractures, all of whom were completely treated, with a think of ± SD shoulder function Constant score of 83.3 ± 16.7 ; and the patients were satisfied with the treatment consequence. 12 however, the efficacy of straight interlocking intramedullary nails in treating fractures of the varus type, a limited character of proximal humeral fracture, has not been reported. In this current prospective navigate discipline, the use of square interlocking intramedullary nails in the treatment of varus proximal humeral fractures achieved excellent outcomes. In total, 20 patients had fracture healing within 3 months, with a average ± SD meter of 2.47 ± 0.41 months. furthermore, none of the patients feel complications such as bone nonunion, delayed curative, infection, failure of inner fixation and ischemic necrosis of the humeral promontory after operation. The patients had a high shoulder function score, with a entail ± SD ASES of 84.0 ± 3.4, a mean ± SD CSS of 83.1 ± 4.8 and a beggarly ± SD DASH score of 80.8 ± 3.7. Although a proximal engage screw came out in one patient, the patient ’ s shoulder motion was restored after screw removal. furthermore, the manipulation of directly interlocking intramedullary nails was effective in preventing re-varus displacement of the humeral head after operating room. In this current cogitation, the mean ± SD postoperative immediate neck-shaft angle was 134.2° ± 7.4° ( range 118°–145° ). During the last follow-up, the mean ± SD neck-shaft angle was 133.7° ± 7.2° ( range 118°–145° ) ; and this result indicated that straight cross-locked intramedullary nails had mechanical advantages in controlling the varus oral sex, and they could resist varus stress produced by rotator handcuff pull. The main intramedullary smash holds the humeral lead and intramedullary nail down implantation improves the median support. therefore, the precondition for the treatment of proximal humeral fracture of varus type using the intramedullary breeze through is that the cram of the humeral pass around the point of intramedullary nail down interpolation is not destroyed ; otherwise, the intramedullary nail can not firmly hold the humeral head. furthermore, the treatment of the proximal humeral fracture with an intramedullary nail down has advantages, including less injury, short secret agent time, lower amount of bleeding during surgery and fast convalescence of postoperative serve compared with a locking plate. In this stream study, the use of straight intramedullary nails with their introduction point at the muscle bellied assign rather than at the traditional tendon share efficaciously prevented the occurrence of iatrogenic rotator cuff wound and the incidence of postoperative shoulder annoyance was significantly reduced.

In this current report, 20 patients had a VAS score of 0–3, with an mean of 1.4, which was like to that in a former analyze. 11 It was reported that 60 % ( 18/30 ) of patients experienced some loss of motion after antegrade complete for humeral shaft fractures. 31 In this stream survey, some patients besides had some loss of motion. In our opinion, this was associated with the patients ’ pre-injury condition, since the mean senesce of patients in this current analyze was 64.2 years, which was a lot higher than that of the previous study. 31 Older patients may have shoulder periarthritis or acromion impact so their postoperative reclamation can be more challenge. A comparison between bilateral shoulder function should besides be included in future studies. The current study had several limitations. First, this was a encase series report and the sample size was small. Although this current analyze showed that the use of upright interlocking intramedullary nails for the treatment of varus proximal humeral fractures had good outcomes, entirely 20 patients were included. In terms of the fracture types, the patients only presented with two-/three-part fractures. A relative cogitation using a control group treated with locking plate obsession combined with fibular homograft augmentation was not performed. thus, far studies should be conducted to validate whether the treatment effect of intramedullary nails on this character of fracture was better than that of locking plates. In decision, locked intramedullary nailing entirely, preferably than locking plate fixation combined with fibular homograft augmentation, was feasible for the treatment of initial varus proximal humeral two-/three-part fractures with meek surgical injury .

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