Comparative Study between Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation For Management Of Proximal Humerus Fracture

Pradeep Choudhari; A Verma; N Jain

Comparative Study between Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation For Management Of Proximal Humerus Fracture

Choudhari P^1*, Verma A², Jain N³

^1* Pradeep Choudhari, Professor, Department of Orthopaedics, Shri Aurobindo Medical College, Indore, Madhya Pradesh, India.

² A Verma, Department of Orthopaedics, Shri Aurobindo Medical College, Indore, Madhya Pradesh, India.

³ N Jain, Department of Orthopaedics, Shri Aurobindo Medical College, Indore, Madhya Pradesh, India.

Background: Fractures of the proximal humerus comprise nearly 4% of all fractures and 26% of fracture of humerus. Surgical options ranges from open reduction internal fixation (ORIF), intramedullary device fixation, external fixation to hemi arthroplasty. We compared the clinical and radiological outcomes of minimal invasive plate osteosynthesis (MIPO) and open reduction and internal fixation (ORIF) in patients with proximal humerus fractures.

Material and Methods: This prospective study included 24 patients with 2 part and 3 part proximal humerus fracture treated with ORIF or MIPO technique, with 12 patients in each group. A matched pair analysis was performed and patients were followed up for 3 months, 6 months and 12 months both radiographically and clinically using Constant and Murley score.

Results: The average of patients was 47.2 years. Average blood loss and mean duration of surgery was 287.50 ml and 102.9 mins, in ORIF group and 198.33 ml and 93.75 mins in MIPO group. The mean Constant Murley Score at 12 months in the MIPO group was 77.00, while in the ORIF group it was 72.33. MIPO group experienced significantly less pain, higher satisfaction in activities of daily living, and greater range of motion. In the MIPO group, only one patient had infection whereas in ORIF group three patients, had complications with one each having infection, varus collapse and malunion

Conclusion: The use of MIPO with a locking compression plate in the management of proximal humerus fractures is a safe and superior option compared to ORIF.

Keywords: Proximal humerus, minimally invasive plate osteosynthesis (MIPO), locking compression plate

Corresponding Author	How to Cite this Article	To Browse
Pradeep Choudhari, Professor, Department of Orthopaedics, Shri Aurobindo Medical College, Indore, Madhya Pradesh, India. Email:	Choudhari P, Verma A, Jain N, Comparative Study between Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation For Management Of Proximal Humerus Fracture. ojmpc. 2020;26(1):24-29. Available From https://ojmpc.com/index.php/ojmpc/article/view/100

Introduction

Fracture of the proximal humerus is the third mostcommon fracture, which accounts for 5%to 9% of all fractures [1]. Treatment of complex fracture patterns (two, three or four part) of theproximal humerus is still a challenging and controversialproblem, which can ranges from non-operativemanagement, percutaneous fracture fixation, openreduction and internal fixation (ORIF), and arthroplasty [2-6].

But osteoporosis-related proximalhumeral fracture requires bettermethods of fixation to decrease the complications associated with fixation failure and long-term immobilization [7-9].

With the introduction and improved design of locking plate, closed manipulative reduction (CMR) technique and minimal invasive technology, the outcome in these fractures in osteoporosis has improved. Although minimal invasive plate osteosynthesis (MIPO) and openreduction and internal fixation (ORIF) showdifference in outcomes and complications in the treatmentof proximal humerus fractures, but it remains unclearwhether MIPO is superior to ORIF [10-13].

Thus the goal of this study was to evaluate the clinical efficacy of CMR techniques combined withMIPO and to compare it with ORIF in the treatment of proximalhumeral fractures.

Materials and Methods

This is a prospective randomized comparative study was conducted at our center on 24 patients ofproximal humerus fracture presenting from December 2016 to August 2018. Before includingthem in this study, informed consent and institutional ethical committeeclearance was obtained.

All skeletally mature patients with Neer’s type II or III displaced proximal humerus fractures were included in the study. Pathologic fractures, open fractures or with associated neurovascular injury or poly trauma were excluded from study. All fractures were classified using NEER'S classification and were randomized to receive treatment either by MIPO or ORIF, both of which was done underbrachial block or general anesthesia in supine position [14].

In MIPO surgery, the firststep was closed manipulative reduction (CMR) following which a longitudinal skin incisionwas given from the lateral edge of theacromion and extending distally for about 3-4 cm. On deep dissection, the deltoid musculature was split along its fibersand greater tuberosity was exposed.

Proximal humerus locking plate wasinserted along the humeral shaft proximally to distally. The plate was positioned just beneath betweenthe periosteal preventing the axillary nerve. Plate position was assessed fluoroscopically. When C-arm fluoroscopyshowed the correct relative position of the plate and fracture, the proximal five to six locking screws wereplaced into the head and with a2 cm-long incision distally over the distal holes in platethree or four screws were placed onto the humeral shaft (Figure 1).

Figure 1: Intra-operated photo (a to e) showing minimal invasive plate osteosynthesis technique (MIPO)

For ORIF group, standard deltopectoral approach was used between pectoralis major and deltoid and the proximalhumeral fracture was exposed and reduced directly. Afterconfirming of satisfactory reduction by C-arm perspective,an appropriate length of the proximal humerallocking plate was selected and placed on the lateralaspect of the greater tuberosity and fixed with lockingscrews into the humeral head and shaft (Figure 2).

Figure 2: Intra-operated photo (a to d) showing open reduction and internal fixation (ORIF) via deltopectoral approach

Post-operatively, shoulder was immobilized by shoulder immobilizer for three days; thereafter patients wereencouraged to start passive shoulder exercises and then slowly full range of motion as per pain tolerance of patient.

Both MIPO andORIF groups were compared for intraoperative parameters surgical incision length, bloodloss and operative time.Clinical and radiological assessment was done regular intervals at 6, 10, 14 weeks and six months postoperatively.

Figure 3: Shoulder and arm AP view pre-operative (a), immediate postoperative (b), and at one year follow-up (c) of proximal humerus fracture treated with ORIF and locking plate. Clinical photo (d to e) showing good results.

Figure 4: Shoulder and arm AP view pre-operative (a), immediate postoperative (b), and at one year follow-up (c) of proximal humerus fracture treated with MIPO technique. Clinical photo (d to f) showing good results.

Union was said when clinically there was no pain or tenderness and radiologically, whenbridging callus was present at fracture site in at least three cortexes in both views. At the final follow-up, thefunctional outcome was evaluated using the Constant-Murley score.

Results

A total of 24 patients, were included in the study, with 12patients in each groups of MIPO andORIF. The overall average age was 47.2 years with average age in the MIPO group to be 45.33 years and 50.25 years in the ORIF group (table 1).

As per Neerclassification, there were 7 (58.3%) cases of type IIfractures and 5 (41.7%) of type III fractures in theMIPO group, while the ORIF group included 4(33.3%) cases of type II fractures and 8 (66.7%) casesof type III fractures.

There was no significant difference between the MIPO and ORIF group in gender, age and Neer type offractures.There were significantdifferences between the two groups in volume of bloodloss and operativetime.

Table 1:Comparison of results of MIPO and ORIF (MIPO – minimal invasive plate osteosynthesis / ORIF – open reduction and internal fixation)

	MIPO	ORIF	p value
Total patients	12	12	-
Mean age (years)	45.33	50.25
Male Female	8 (66%) 4 (33%)	7 (58%) 5 (41%)	-
Right Left	7 (58%) 5 (41%)	6 (50% 6 (50%)	-
Mode of injury a. Fall from height b. Vehicle accident c. Self-fall	1 (8%) 5 (41%) 6 (50%)	1 (8%) 7 (58%) 4 (33%)
Neer’s classification a. Two part b. Three part	7 (58%) 5 (41%)	4 (33%) 8 (66%)
Intra-operative parameter a. Mean Surgical Time (min) b. Mean Blood Loss (ml)	93.7 198.33	102.9 287.5	0.007 0.006
Mean Union time (weeks)	11.0	11.92	0.13
Constant Murley score a. Poor (<55) b. Moderate (56- 70) c. Good (71-85) d. Excellent (>85)	77.00 0 (0%) 1 (8%) 11 (91%) 0 (0%)	72.3 0 (0%) 2 (16%) 10 (83%) 0 (0%)	0.096
Complications a. None b. Malunion c. Infection d. Varus collapse	11 (91%) 0 (0%) 1 (8%) 0 (0%)	9 (75%) 1 (8%) 1 (8%) 1 (8%)

Compared with the ORIF group which had an average of 287.50ml of blood loss and 102.9 min of mean surgery time, the MIPO group had less blood loss with anaverage of 198.33 ml and shorter operation time with an averageof 93.75 minutes, both of with was significant with p value <0.05 (Figure 3 & 4).

The Constant score was higher in the MIPO group at 3 and 6 month follow-up compared tothe ORIF group. In addition,patients in the MIPO group experienced significantlyless pain, higher satisfaction in activities of daily living,and greater range of motion at the 3 and 6 monthsfollow-up (p < 0.05). Although, the level of strength wasnot significantly different at same time (p > 0.05).

The mean Constant Murley Score at 12 months in the MIPO group was 77.00 ± 4.75, while in the ORIF group it was 72.33 ± 8.00, which was not statistically significant (p>0.05). In the MIPO group, only one patient had infection whereas in ORIF group three patients, had complications with one each having infection, varus collapse and malunion (table 1).

Discussion

Proximal humerus fractures are common fractures and treatmentshould concentrate on maximizing the functional outcomeswith minimal pain and disability [2-7].

In the present study, we compared the outcome of proximal humerus fractures treated with MIPO and ORIF in comparable groups with nosignificant differences between the groups in gender, age and Neer’s type of fracture.

Intra-operative parameters (duration of surgery, blood loss), post-operative functional outcome and union time of MIPO group wasbetter than that of ORIF, which was statistically significant. Although, thefunctional outcomes of these two groups as evaluated byConstant-Murley scores showed that MIPObrought better results than ORIF but the difference was not significant at one year follow up.

Further the postoperativecomplications like infection, varus collapse and malunion were lesser in MIPO group. In our study, in MIPO group also, few postoperative complicationsoccurred, including superficial infection, numbness ofanterior edge skin, and slight pain. Many reported casestreated with this technique had similar complications [15-19].

Superior result of MIPO over ORIF, as seen by our and other studies is due to decreased surgical trauma to the soft tissue andpreservation of periosteal circulation in MIPO [20].

This could also lead to higher complications like nonunion, necrosis, pain and infectionsin ORIF group as compared to MIPO group, whichis also supported by many reports [7,15-19].

Thebetter outcome and lower complications of the MIPO group may be either dueto the fact that there was better reduction with less operative time, or to the fact that less damage is causedto the blood supply of the fracture fragments [13,21,22].

The MIPO technique may retain more osteogenicfracture healing factors at the fracture site than ORIF [23].

Conclusion

Our study shows that MIPO with LCP requires lesssurgery time, causes less blood loss, shortens hospitalstay, results in less scarring, and is cosmetically moreappealing and acceptable to female patients compared toORIF. Further, MIPO provides better functional results and has less morbidity at one yearfollow-up, although our study is limited by a lesser number of patients.

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Authors state no conflict of interest.	Non Funded.	The conducted research is not related to either human or animals use.	12.32	All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

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