Commentary & Perspective

Commentary & Perspective on
"Severely Impacted Valgus Proximal Humeral Fractures: Results of Operative Treatment"
by C. Michael Robinson, BMedSci, FRCSEd(Orth), and Richard S. Page, BMedSci, FRACS(Orth)

Commentary & Perspective by
Christian Gerber, MD*,
University of Zurich, Zurich, Switzerland

This manuscript describes operative treatment of severely impacted valgus fractures of the proximal part of the humerus with use of open reduction, grafting of the defect with a bone substitute, and internal fixation. It documents good clinical and radiographic results at one to maximally two years postoperatively in a population with an average age of sixty-seven years. When analyzing these excellent results, however, a few observations are in order:

It is important to remember that the population in this series is special. Whereas the valgus-impacted fracture has hitherto been documented to be a fracture of the proximal part of the humerus of the young individual with an average age of forty-nine years in the study of Jakob et al.¹ and an average age of fifty-two years in the study of Resch et al.², the present study deals with a population with an average age of sixty-seven years and in which twenty of the twenty-five patients are older than sixty years. This means that the usual age range reported in other studies is the exception in this series. Conversely, the degree of impaction in the present series (average, 37°) corresponds almost exactly to that in the study of Resch et al. (average, 38°).

Also, a valgus impaction fracture is a fracture of compression, and we are not aware of other series that have documented lesions of the axillary nerve, so it is probable that the two partial axillary nerve lesions that were documented in the present series are contusions at the level of the deltoid.

And finally, before a general adoption of the authors' technique, it would be interesting to know the answers to some particularly important questions that were not addressed in the manuscript.

First, the main risk factor for the development of osteonecrosis is the level of the fracture medially at the calcar of the humerus^2,3. This level is unknown for the fractures in this series. In addition, we do not know whether the humeral head was laterally translated or not, i.e., whether the medial hinge was intact or not, which is another key factor for prognosis in terms of survival of the epiphyseal segment and for the intraoperative ease of reduction.

Second, the displacement of the greater tuberosity was not well defined: In valgus-impacted fractures, a 1-cm distance between the upper part of the head and the greater tuberosity occurs even when the greater tuberosity has remained in place. Severe posterior or proximal displacement relative to the shaft is rare, and reduction of the head segment may often suffice to reduce the fracture without the performance of major reduction maneuvers for the greater tuberosity.

Third, a longitudinal rent in the rotator cuff should not be called "a rotator cuff tear" as this implies a different entity for most surgeons. If the rent is longitudinal, it may be that repair is neither necessary nor beneficial. As in most series in which the authors do not report a disinsertion of a tendon from its attachment at the tuberosity, a tendon-to-bone repair was not performed. Therefore, it is possible that the side-to-side suturing of the rotator cuff enhanced the stability of the construct and that the torn tendon had not been repaired effectively. It is not clear why the authors repaired the cuff before they elevated the head, and it would have been interesting to know if they had been able to assess the quality of reduction by inspection of the tendon through the longitudinal rent.

Fourth, the authors used a transdeltoid approach and performed an acromioplasty: It would be helpful to know in detail how the deltoid was treated because there was almost no postoperative stiffness despite open reduction and internal fixation plus immobilization for two weeks and there were no deltoid detachments postoperatively. It is noteworthy that an entirely normal population with an average age of sixty-seven years did not have an average forward flexion better than 164° as measured with the Constant Score.

Fifth, certainly, as the authors correctly point out, there is no evidence to suggest that the bone substitute used in this study had any greater beneficial effect than if autogenous or allograft bone had been used. Their concerns about heat when using polymethylmethacrylate are hypothetical. In many countries, even in the developed world, the cost of such material may be a major issue as long as there is no proven advantage over less costly alternatives.

Lastly, a follow-up period of one year, and of two years in less than half of the patients, is surprisingly short and is clearly too short to make a final assessment of the risk of the development of osteonecrosis and collapse with secondary deterioration of function. The authors have, however, demonstrated that they can obtain and maintain near anatomical reduction in all cases, which thereby facilitates the performance of arthroplasty should osteonecrosis ensue at a later time.

This is an excellent study that answers some questions and raises more new ones. It documents approximately the same results as the studies previously cited^1,2 for the same fracture type, but in an older population. It will be interesting to see whether use of a bone substitute will be superior to bone grafting, whether the low rate of osteonecrosis can be maintained over time, and whether other, less experienced surgeons can reproduce the excellent functional results with such a low rate of complications.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures: an anatomical cadaver study. J Bone Joint Surg Br. 1993;75:132-6.
2. Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73:295-8.
3. Resch H, Beck E, Bayley I. Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg. 1995;4:73-80.