Orthopedic surgeons from around the country recently published a study titled "Intermediate Outcomes Following Percutaneous Fixation of Proximal Humeral Fractures." The surgeons examined 39 patients who were treated with percutaneous reduction and fixation for proximal humeral fractures at Mount Sinai School of Medicine in New York City, Barnes-Jewish Hospital in St. Louis and the University of Pennsylvania Health System in Philadelphia. They obtained follow-up data from 27 patients with a minimum of three years after surgery and found:• Osteonecrosis in 26 percent of the patients
• Posttraumatic osteoarthritis was present in 27 percent of the patients
• Five cases of osteonecrosis among the 10 patients who had four-part fractures while six of the patients in this group reported posttraumatic osteoarthritis
• Two cases of osteonecrosis among the 12 patients who had three-part fractures while four of these patients reported posttraumatic osteoarthritis
• None of the five patients with two-part fractures reported osteonecrosis or posttraumatic osteoarthritis
Evan Flatow, MD, the Lasker Professor and Chair of Leni and Peter W. May Department of Orthopedic Surgery at the Icahn School of Medicine at Mount Sinai Medical Center, discusses the study and what the results mean for the future.
Q: What prompted you and your colleagues to research this area and publish your findings?
Dr. Evan Flatow: I think the field of orthopedics in general has tried to move to minimally invasive approaches both in arthroscopy for shoulder problems as well as minimal incisions for bigger cases. Fractures have been very challenging because cutting the shoulder open damages the soft tissue and blood supply for healing. The ability to use a minimally invasive procedure to fix fractures is a big advance.
We had previously published on this topic, and others have published as well, with short term results of trying to fix fractures percutaneously, using pins, screws and little devices to move the pieces around. When we followed the patients for long term outcomes, we still had excellent results and good motion and function.
Q: What is unique and significant about the percutaneous procedure?
EF: The rate of avascular necrosis — loss of blood supply to the head of the humerus — has a lower rate with minimally invasive approaches, but the rate goes up with time. Two to three years after surgery, patients are more likely to develop complications, so they have to be closely followed. If you do try to fix these fractures with locked plates and screws, and the patient has avascular necrosis, the head collapses around the screws which then damage the joint.
However, with the minimally invasive percutaneous approach most of the hardware is removed sparing the joint if avascular necrosis occurs. I think this has revolutionized the treatment of complex fractures.
Q: How could the results of this study impact orthopedic surgery?
ET: It could have a big impact for patients with severe fractures. There are arthroscopic approaches for small tuberosity fractures, but they aren't applicable as much to complex proximal humeral fractures, with a few exceptions. Minimally invasive approaches where we put plates in through small incisions are also an option. This percutaneous technique can further reduce morbidity in fracture care.
This is a special technique for people who do a lot of these types of repairs. It's not for everyone, and it's not for every fracture. There are some fractures that are treated by traditional methods, but in the future I think more specialized surgeons will be doing this.
Q: Where do you see the field headed in the future?
ET: Some severe fractures do better with joint replacement, and I think in the future we are going to have implant systems that will work better for fracture care. Right now we have one set of instruments or one approach to fix fractures and others for shoulder replacement for fracture, and they are all different systems. In the future, I think we will have comprehensive systems that can support the full array of techniques.
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