Comparison of the Effects of Proximal Humeral Internal Locking System (PHILOS) Alone and PHILOS Combined with Fibular Allograft in the Treatment of Neer Three- or Four-part Proximal Humerus Fractures in the Elderly

Abstract

Objective: To compare and analyze the clinical outcomes of the proximal humeral internal locking system (PHILOS) alone and the PHILOS combined with fibular allograft in the treatment of Neer three- and four-part proximal humerus fractures (PHF) in the elderly.

Methods: From January 2014 to January 2018, a total of 42 elderly patients with Neer three- or four-part PHF admitted to our hospital were randomly divided into observation group and control group, with 21 patients in each group. The observation group was treated with the PHILOS combined with fibular allograft. The control group was treated with the PHILOS alone. Perioperative parameters and fracture classification were recorded in the two groups. Function results were assessed by Visual Analog Scale (VAS), Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, and the Disability of Arm-Shoulder-Hand (DASH) score. Radiological results were evaluated using the neck-shaft angle (NSA) and humeral head height (HHH), and complications were also recorded in each group.

Results: There were no significant differences between the two groups in terms of preoperative status, age, gender, cause of trauma, fracture site, and fracture classification. The average follow-up time was 12 months. At the last follow-up, the VAS and DASH observation groups were lower than the control group, and there was significant difference between the two groups (P < 0.05). The CMS and ASES were higher in the observation group than the control group, and there was significant difference between the two groups (P < 0.05). The mean difference in the NSA and HHH were lower in the observation group than the control group, and there was a significant difference between the two groups (P < 0.05). There was one postoperative complication in the observation group, which was humeral head avascular necrosis (AVN). There were seven postoperative complications in the control group, including three cases of humeral head collapse and three cases of screw cutout and one case of humeral head AVN. The incidence of postoperative complications in the observation group was significantly lower than the control group (P < 0.05), there was a significant difference between the two groups.

Conclusions: For Neer three- or four-part PHF in the elderly patients, PHILOS fixation with fibular allograft shows satisfactory short-term results with respect to humeral head support and maintenance of reduction, and may reduce the incidence of complications associated with fixation using a PHILOS alone.

Keywords: Anatomical allograft; Elderly; Fibular shaft; Proximal humeral internal locking system; Proximal humerus fractures.

Figure 1

(A) Fibular allograft (12 mm×60 mm); (B) Insertion of fibular allograft.

Figure 2

(A) (The illustration of the PHILOS combined with fibular allograft technology): A 2.0 mm Kirschner‐wire (K‐wire) was inserted into the humeral head to control rotation, and a periosteal elevator was used as a joystick at the fracture site to obtain reduction. After reduction of the greater tuberosity and humeral head, one or two 1.5 mm K‐wires were used for temporary fixation；(B) The allograft humerus is placed in the distal medullary cavity of the fracture, and the medial support is used to prevent the deformity and collapse of the humeral head in the long term; (C) Rotator cuff sutures were passed through the proximal humeral locking plate, and this was then slid from proximal to distal along the lateral aspect of the shaft, under the axillary nerve. The rotator cuff sutures were tied into place through eyelets on the plate, fixation was then obtained with screws and the wound was closed.

Figure 3

(A) The humeral neck‐shaft angle (NSA) was defined as the angle between a line that is perpendicular to the articular segment or atomic neck of the humerus and a line that bisects the humeral shaft; (B) The humeral head height (HHH) was defined as the distance between uppermost edge of the plate and the uppermost part of the humeral head.

Figure 4

PHILOS fixation alone in a 65‐year‐old male patient with a four‐part proximal humeral fracture on the right side. (A) X‐ray film before surgery; (B) CT before surgery; (C) 3D CT before surgery; (D) X‐ray film after surgery; (E) X‐ray film 3 months after surgery; (F‐J) Function of patient's upper arm at the last follow‐up.

Figure 5

PHILOS fixation with fibular allograft in a 76‐year‐old male patient with a four‐part proximal humeral fracture on the right side. (A) X‐ray film before surgery; (B) CT before surgery; (C) 3D CT before surgery; (D) X‐ray film after surgery; (E) X‐ray film 3 months after surgery; (F–J) Function of patient's upper arm at the last follow‐up.

Figure 6

PHILOS fixation with fibular allograft in three patients with a four‐part proximal humeral fracture on the right side. (A) X‐ray film before surgery; (B) X‐ray film after surgery; (C) X‐ray film 1 month after surgery; (D) X‐ray film 3 months after surgery.

Figure 7

PHILOS fixation with fibular allograft in three patients with a four‐part proximal humeral fracture on the right side. (A) X‐ray film before surgery; (B) X‐ray film after surgery; (C) X‐ray film 1 month after surgery; (D) X‐ray film 3 months after surgery.

Figure 8

PHILOS fixation with fibular allograft in three patients with a four‐part proximal humeral fracture on the right side. (A) X‐ray film before surgery; (B) X‐ray film after surgery; (C) X‐ray film 1 month after surgery; (D) X‐ray film 3 months after surgery.