Commentary & Perspective on
"Open Reduction and Internal Fixation of Three and Four-Part Fractures of the Proximal Part of the Humerus"
by A.J. Wijgman, MD, et al.

Commentary & Perspective by
Evan Flatow, MD*,
Department of Orthopaedic Surgery, The Mount Sinai Hospital, New York, NY

While most fractures of the proximal part of the humerus heal well when managed nonoperatively, those with substantial displacement, comminution, or dislocation of the humeral head represent a difficult clinical challenge. Indeed, Neer originally developed humeral head replacement for treatment of these severe injuries in response to the poor results that he observed after the standard options of nonoperative treatment, open reduction and internal fixation, or removal of the humeral head¹. Much has been written about the reliability of fracture classifications, and the Neer classification remains the most practical and widely used method².

Neer advocated humeral head replacement for four-part fracture-dislocations because of the high incidence of avascular necrosis and the poor results of either nonoperative or operative treatment of these injuries³. He did not consider fracture to be an indication for humeral head replacement unless a complete dislocation of the head has occurred, so that the head is not in contact with the glenoid and is devoid of soft-tissue attachments. Open reduction and internal fixation remains a controversial method of treatment for these fractures. Few investigators have advocated humeral head replacement to treat three-part fractures of the proximal part of the humerus except in elderly patients with comminuted, osteoporotic bone as a salvage procedure⁴. Even then, the rationale for this treatment is usually its ability to provide secure fixation and simplified rehabilitation, not as a method of preventing avascular necrosis. Furthermore, the category of "valgus-impacted" four-part fractures has been better defined as a subgroup that is amenable to fixation without replacement⁵. These fractures generally have some medial soft-tissue attachment and thus are not "classic" four-part fracture-dislocations. Indeed, this type of fracture may be thought of as a forme fruste of the four-part fracture-dislocation with lateral displacement⁶. In any event, the evolving treatment for these fractures is percutaneous reduction and fixation⁷ rather than open reduction and internal fixation.

Wijgman and coworkers, in this issue of The Journal, report the results of open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. They concluded that open reduction and internal fixation with cerclage wires or a T-plate "should be considered even for patients with fracture-dislocation patterns that are associated with a high risk for avascular necrosis of the humeral head as this complication did not preclude a good result." Is that conclusion justified? I will endeavor to discuss this issue fairly, but the reader should be aware that I benefit financially from the sale of a humeral head replacement manufactured by Zimmer, Inc.

Of 109 patients with a three or four-part fracture of the proximal part of the humerus that was treated surgically, sixty were followed for an average of ten years after open reduction and internal fixation. The authors are to be commended for the length of follow-up and the excellent data presented. However, this series includes follow-up data for only nine patients with four-part fracture-dislocations, which is the group of controversial interest. Avascular necrosis developed in eight (89%) of these nine patients. Only one achieved an excellent result, five had a good result, and two had a poor result. The results were defined on the basis of the Constant score; a score of 71 to 85 points indicated a good result. The authors stated that muscle strength was measured with use of a 1 kg weight "as described by Constant," yet the method cited uses a spring-balance or force gauge, and 25 points were given for a maximum of "25 pounds pull"⁸. In my experience, few elderly patients achieve all of these points. Figure 4, which provides an indication of the good results in a patient who had sustained a four-part fracture-dislocation treated with a T-plate, shows avascular necrosis with collapse of the humeral head, hardware that is evidently into the joint, and 100° of elevation. A patient who has had a shoulder arthrodesis can elevate to the horizontal! The major achievement in this case was pain relief. However, two (22%) of the nine patients who had a four-part fracture-dislocation had pain and a poor result. A further source of confusion is that seventeen patients in the original study population were excluded from analysis because they underwent a hemiarthroplasty during the study period because of delayed fracture treatment or after an intraoperative failure of osteosynthesis due to severe comminution or osteoporosis. How many of these patients were comparable to the nine patients with a four-part fracture-dislocation who underwent open reduction and internal fixation?

To what should we compare these results? Neer and McIlveen reported largely excellent results of humeral head replacement for the treatment of fractures of the proximal humerus⁹. The combination of such good results and the expectation of poor results of open reduction and internal fixation of four-part fracture-dislocations because of the increased risk for development of avascular necrosis suggested that humeral head replacement should be the standard treatment for these injuries. However, investigators in other series noted erratic functional results of hemiarthroplasty in patients with these fractures^10-15. Furthermore, Gerber et al. reported that, when accurate reduction is achieved, open reduction and internal fixation can lead to acceptable results (as good as those achieved in a concurrent series of patients treated with humeral head replacement), even when avascular necrosis occurred¹⁶. At a recent meeting, Dr. Gerber compared his experience of the "best" results of open reduction and internal fixation (those retrospectively judged to have achieved anatomic reduction of the greater tuberosity) with the average results of humeral head replacement (not just those with anatomic repair of the tuberosity). Nevertheless, that work and the current series illustrate the important point that avascular necrosis is not always a disaster, and its development can be consistent with a functional result that the patient finds acceptable.

So, is avascular necrosis irrelevant? As I interpret Table I in the article by Wijgman et al., five (23%) of twenty-two patients in whom avascular necrosis developed had a poor result and only two (9%) had an excellent result, whereas only three (8%) of thirty-eight patients without avascular necrosis had a poor result and sixteen (42%) had an excellent result. Ninety-two percent of those without avascular necrosis achieved a good or excellent result compared with 77% of those who had avascular necrosis. A lack of statistical significance is not proof of a lack of difference, but the trend favors the interpretation that avascular necrosis is associated with adverse outcomes.

Recent studies have identified factors prognostic of better results of humeral head replacement after fracture of the proximal part of the humerus^5,17-19, suggesting that predictable and durable results may be achieved by experienced surgeons if tuberosity healing occurs in an anatomic position. Wijgman et al. have made a strong case that open reduction and internal fixation remains a valuable option for treatment of many fractures of the proximal part of the humerus. In my own practice, percutaneous techniques have replaced open reduction and internal fixation for the treatment of 90% of fractures of the proximal part of the humerus, while I still use humeral head replacement for treatment of the four -part fracture-dislocation pattern seen in nine of the patients in the present study. Further study, perhaps in prospective series, is needed to further define the indications for each of these approaches. The surgeon must determine case by case which treatment is best until outcomes data are collected that will shed further light on this important topic.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. The author did receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Zimmer, Inc.). In addition, a commercial entity (Zimmer, Inc.) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

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