head JofIMAB
Journal of IMAB - Annual Proceeding (Scientific Papers)
Publisher: Peytchinski Publishing Ltd.
ISSN: 1312-773X (Online)
Issue: 2021, vol. 27, issue4
Subject Area: Dental Medicine
DOI: 10.5272/jimab.2021274.4072
Published online: 28 October 2021

Original article

J of IMAB. 2021 Oct-Dec;27(4):4072-4076
Konstantin Totev1ORCID logo Corresponding Autoremail, Georgi Dimitrov1ORCID logo, Lyubomira Toteva2ORCID logo, Svilen Todorov1ORCID logo, Steliyan Lungarov1ORCID logo,
1) Department of orthopaedics and traumatology, Faculty of Medicine, Medical University - Pleven, Bulgaria.
2) Department of physical medicine, rehabilitation, ergotherapy and sport, Faculty of Public health, Medical University - Pleven, Bulgaria.

Proximal humerus presents the second most frequent site of posttraumatic osteonecrosis. This complication is usually related to poor functional outcomes. The aim of this study is to identify and analyze the risk factors for posttraumatic humeral head osteonecrosis in surgically treated patients.
Ninety-one patients with 92 acute proximal humeral fractures were operated on for a period of 39 months. Operative methods include open reduction and internal fixation and closed reduction and percutaneous fixation. Fractures were classified according to Neer, AO and LEGO classifications. The mean age of patients was 60.9 years. From 91 operated patients for follow-up were available 82. The mean follow-up period was 15 months. Patient data was collected prospectively.
Functional results are present using age and gender adjusted Constant score. In 41 patients, the result is excellent, in 28-good, in 11-fair and in 3 poor.
Bone union was evident in all cases. No deep wound infections, nerve injuries, vascular injuries and implant failure were observed.  
Osteonecrosis was seen in 5 (6.1%) patients. Patients with posttraumatic osteonecrosis had significant lower Constant results. Analyzing the pre- and intraoperative factors in patients with osteonecrosis, we find that the most significant factors for this complication are increasing fracture severity and а combination of short medial metaphyseal extension and disrupted medial hinge.

Keywords: proximal humerus fracture, osteonecrosis, risk factors,

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Please cite this article as: Totev K, Dimitrov G, Toteva L, Todorov S, Lungarov S. Risk factors for humeral head osteonecrosis in patients with proximal humeral fractures treated operatively. J of IMAB. 2021 Oct-Dec;27(4):4072-4076. DOI: 10.5272/jimab.2021274.4072

Corresponding AutorCorrespondence to: Konstantin Totev, MD, PhD, Department of orthopaedics and traumatology, Faculty of Medicine, Medical University, Pleven; 89, Ruse Blv., Pleven 5800, Bulgaria; E-mail: kztotev@abv.bg

1. Court-Brown CM, Garg A,  McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001 Aug; 72(4):365-371. [PubMed]
2. Palvanen M,  Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res.2006 Jan;442:87-92. [PubMed]
3. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970 Sep;52(6):1077-89. [PubMed]
4. Tamai K, Ishige N, Kuroda S, Ohno W, Itoh H, Hashiguchi H, et al. Four-segment classification of proximal humeral fractures revisited: A  multicenter study on 509 cases.  J Shoulder Elbow Surg. 2009 Nov-Dec;18(6):845-50. [PubMed]
5. Robinson CM, Stirling PH, Goudie EB, MacDonald DJ, Strelzow JA. Complications and long-term outcomes of open reduction and plate fixation of proximal humeral fractures. J Bone Joint Surg Am. 2019 Dec 4;101(23):2129-2139. [PubMed]
6. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. [PubMed]
7. Large TM, Adams MR, Loeffler BJ, Gardner MJ. Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures. J Am Acad Orthop Surg. 2019 Nov 1;27(21):794-805. [PubMed]
8. Patel S, Colaco HB, Elvey ME, Lee MH. Post-traumatic osteonecrosis of the proximal humerus. Injury. 2015 Oct;46(10):1878-84. [PubMed]
9. Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative asessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am. 2010 Apr;92(4):943-8. [PubMed]
10. Campochiaro G, Rebuzzi M, Baudi P, Catani F. Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis Musculoskelet Surg. 2015 Sep;99 Suppl 1:S9-15. [PubMed]
11. Resch H, Aschauer E, Povacz P, Ritter E. Closed Reduction and Fixation of Articular Fractures of the Humeral Head. Techniques in Shoulder&Elbow Surgery. 2000 Sep;1(3):154-162.
12. Beeres FJP, Hallensleben NDL, Rhemrev SJ, Goslings JC, Oehme F, Meylaerts SAG, et al. Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications. Arch Orthop Trauma Surg. 2017 Dec;137(12):1685-1692. [PubMed]
13. Court-Brown C, McQueen M, Tornetta P. Trauma (Orthopaedic Surgery Essentials Series) 1st Edition. Lippincott Williams & Wilkins. January 1, 2006. p.99 [Internet]
14. Sturzenegger M, Fornado E, Jacob R. Results of surgical treatment of multifragmented fractures of the humeral head. Arch Orthop Trauma Surg. 1982; 100 (4):249-259. [PubMed]
15. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005 May;434:123-9. [PubMed]
16. Frankle MA, Greenwald DP, Markee BA, Ondrovic LE, Lee WE 3rd. Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures. J Shoulder Elbow Surg. 2001 Jul-Aug;10(4):321-6. [PubMed]
17. Dimitrov G, Totev K, Simeonov M, Ivanov I, Asparouhov A. Antero-lateral approach to the proxilal humerus. Ortop Trauma 2011; 3(48):104-110
18. Bastian JD, Hertel R. Initial postfracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg. 2008 Jan-Feb;17(1):2-8. [PubMed]
19. Padegimas EM, Zmistowski B, Lawrence C, Palmquist A, Nicholson TA, Namdari S. Defining optimal calcar screw positioning in proximal humerus fracture fixation. J Shoulder Elbow Surg. 2017 Nov;26(11):1931-7. [PubMed]
20. Gerber C, Lambert SM, Hoogewoud HM. Absence of avascular necrosis of the humeral head after posttraumatic rupture of the anterior and posterior humeral circumflex arteries. A case report. J Bone Joint Surg. 1996 Aug;78(8):1256-9. [PubMed]
21. Belayneh  R, Lott A, Haglin J, Konda S, Zuckerman JD, Egol KA. Osteonecrosis after surgically repaired proximal humerus fractures is a predictor of poor outcomes. J Orthop Trauma. 2018 Oct;32(10):e387-e393. [PubMed]
22. Sproul RC, Iyengar JI, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011 Apr;42(4):408-13. [PubMed].

Received: 26 March 2021
Published online: 28 October 2021

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