Kamikovski Ivan, Wengle Lawrence, Sheth Ujash, Nam Diane
Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Division of Orthopedics, Department of Surgery, University of Toronto, Toronto, ON, Canada.
JSES Rev Rep Tech. 2023 Dec 18;4(3):438-448. doi: 10.1016/j.xrrt.2023.11.003. eCollection 2024 Aug.
Fractures of the proximal humerus account for 4%-8% of injuries to the appendicular skeleton. Most are stable, minimally displaced osteoporotic fractures in the elderly, and are the result of low-energy falls. A large majority of these patients regain adequate shoulder function without operative intervention. Surgery is considered in approximately 20% of patients because they require improved shoulder function for their activities of daily living or because of the significant deformity of their fracture and the need to restore functional alignment, length, and rotation in active, higher demand individuals. However, fixation of these fractures can pose a challenge due to poor bone quality and displacing forces of the rotator cuff. This is especially true in 3-part and 4-part fractures. These factors lead to the high failure rates seen with early attempts at osteosynthesis. In the last 2 decades, locking plate technology has been an innovation in treating these complex fractures. Despite the improvements in torsional strength and rigidity, outcome studies on locking plate technology demonstrate equivocal results with complication rates as high as 20%-30% and a revision rate of 10%. Specifically, these complications include avascular necrosis, varus collapse, intra-articular screw penetration, and postoperative stiffness. Varus collapse occurs when the weak osteoporotic bone fails around the implant. In turn, fibular strut endosteal augmentation was introduced to provide additional support and decrease implant failure rates in displaced fractures with varus coronal malalignment and significant metaphyseal bone loss. Although clinically successful and biomechanically superior to plate-only constructs, a few concerns remain. In turn, we introduce a novel technique of creating individual cancellous femoral head allograft struts or "French fries" that provides structural support for the humeral head but does not have the potential problems of a cortical fibular strut.
肱骨近端骨折占四肢骨骼损伤的4%-8%。大多数是老年人的稳定、移位极小的骨质疏松性骨折，是低能量跌倒的结果。这些患者中的绝大多数在没有手术干预的情况下恢复了足够的肩部功能。约20%的患者考虑进行手术，因为他们的日常生活活动需要改善肩部功能，或者因为骨折畸形严重，需要在活动量大、需求高的个体中恢复功能对线、长度和旋转。然而，由于骨质质量差和肩袖的移位力，这些骨折的固定可能具有挑战性。在三部分和四部分骨折中尤其如此。这些因素导致早期骨合成尝试的失败率很高。在过去20年中，锁定钢板技术一直是治疗这些复杂骨折的一项创新。尽管扭转强度和刚度有所提高，但关于锁定钢板技术的结果研究显示结果不明确，并发症发生率高达20%-30%，翻修率为10%。具体而言，这些并发症包括缺血性坏死、内翻塌陷、关节内螺钉穿透和术后僵硬。当薄弱的骨质疏松性骨在植入物周围失效时，就会发生内翻塌陷。反过来，引入腓骨支撑骨内膜增强术以提供额外的支撑，并降低内翻冠状位畸形和严重干骺端骨质流失的移位骨折的植入物失败率。尽管在临床上取得了成功，并且在生物力学上优于仅使用钢板的结构，但仍存在一些问题。反过来，我们引入了一种新技术，即制作个体化的松质骨股骨头同种异体支撑物或“薯条”，为肱骨头提供结构支撑，但没有皮质腓骨支撑物的潜在问题。
