Download Chapter 1 Surgical Technique for Minimally Invasive

Bone and Joint Disorders
Bone and Joint Disorders
Chapter 1
Surgical Technique for Minimally
Invasive Plate Fixation for Proximal
Humeral Fractures: Tips and Tricks
Héctor J Aguado1,2*, Clarisa Simón Pérez2,3, Belén García
Medrano3, Juan Mingo Robinet4, Virginia García Virto1
and Miguel Ángel Martín Ferrero2,3
Copyright: © 2016 Héctor J Aguado, et al.
This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction
in any medium, provided you give appropriate credit to
the original author(s) and the source.
Abstract
Trauma Unit at Hospital Clínico Universitario in Valladolid,
Spain
2
Medical School, Universitiy of Valladolid, Spain
3
Upper limb Unit at Hospital Clínico Universitario in Valladolid,
Spain
4
Complejo Asistencial in Palencia, Spain
1
Corresponding Author: Héctor J Aguado, Servicio de
Traumatología y Cirugía Ortopédica 5ª planta Este, Hospital Clínico Universitario, C/ Avenida de Ramón y Cajal
3, 47003 Valladolid, Spain, Tel:+34 983420000; Email:
[email protected]
*
First Published July 28, 2016
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The objective of this chapter is to describe the surgical technique of fixation with polyaxial locking plates
through a minimally invasive approach for the treatment
of proximal humeral fractures.
The objective of the reduction is to achieve the “chair
concept” given by the St. Gallen group. The fracture fragments (head, greater tuberosity, lesser tuberosity and the
diaphysis with the medial metaphysis) are reduced to
build a chair structure: the head is the seat and stands on
three legs, which are the greater tuberosity, lesser tuberosity and the medial metaphysis or calcar. This chair finally
stands on the diaphysis to complete fracture reduction.
Preoperative planning is key to correctly address all the
fracture fragments. Stay sutures will help in the reduction
of the tuberosities; and through the “tuberosity window”,
the gap created between both tuberosities, head reduction
can be achieved.
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Fracture fixation should be built with a locking plate
for early movement, and in a minimally invasive way, to
preserve soft tissues. External aiming devices with sleeves
systems will allow percutaneous screw placing.
Complications are related with poor surgical technique. Screw joint penetration is the most frequent. Axillary nerve injuries, although very serious complication,
hardly occur if the surgical technique is followed step by
step.
Throughout this chapter we will explain, step by step,
the surgical technique to reduce and fix proximal humeral
fractures successfully. Tips and tricks are presented so patients can start physiotherapy right after the operation.
(Video: MIPO surgical technique for proximal humeral fracutres: https://youtu.be/T4o_a8_9R0A)
Introduction
The treatment of proximal humerus fractures (PHF)
has been and it is now controversial [1]. Conservative
treatment is considered the gold standard when compared
with the different treatment options available: percutaneous K-wires, open reduction and fixation with classical or
locking plates, IM locking nails, or shoulder prosthesis
[2-12]; but no conclusions according to which is the best
treatment for these fractures can be withdrawn.
The increase of life expectancy has raised the incidence of these fractures; on the other side, quality of life
has increased the activity level and demands from aged
osteoporotic patients [13]. Fixation with polyaxial locking plates through a minimally invasive surgery (MIS) approach can provide a stable osteosynthesis in osteoporotic
bone with low surgical injury to an elderly patient [14,15].
Soft tissues damage during surgery remains at its minimum. This would allow immediate physiotherapy treatment and recovery [16,17].
Indications for Minimally Invasive Plating Osteosynthesis (MIPO) in PHF include almost all fractures independent from the number of fragments and the grade of
displacement. Intra-articular head split fractures can also
be reduced and fixed through a MIS approach. In all cases
a deep knowledge of the fracture and the fragments displacement is necessary preoperatively. Proper X-ray views
and a CT-scan study should give enough information of
the fracture, and if fixation with a plate and screws is possible.
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A formal contraindication for MIPO is when the
fracture is associated with a glenohumeral dislocation; in
these cases, open reduction is advised. In cases with poor
bone stock such as an intra articular head fracture in old
patients, the screws won´t have any bone purchase and
the fixation will fail. In such cases MIPO is contraindicated and other treatment options should be considered.
Throughout this chapter, we will explain the surgical techniquein the treatment of PHF step by step: from
the operation room setup to reduction and fixation with a
polyaxial locking plate via MIS [16,17].
Patient Position
Beach-chair position with the shoulder girdle and the
upper limb overlaying from the side of the operation table.
This way the upper limb can be freely placed in any position. The arm hangs alongside the trunk with the shoulder in 0º abduction and neutral rotation. The forearm lays
beside the thigh, on a support, in a way the elbow hangs
suspended (Figure 1). As the beach chair position is in 80º
vertical it may reduce cerebral perfusion; to avoid this serious complication reach this position slowly [18]. With
this position, gravity helps in the reduction of the neck
and shaft fracture fragment; avoiding medial and proximal rising displacement of the proximal diaphysis (Figure
1, X-ray image).
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Figure 1: Beach-chair position with the shoulder girdle and the upper
limb overlaying from the side of the operation table. C-Arm coming
from the head and same side. Pure antero-posterior view of the glenohumeral joint on the X-ray image.
Intraoperative X-Ray
C-arm from the patient’s head at the fracture side.
Pure antero-posterior (AP) glenohumeral views are used,
with the C-arm perpendicular to the scapular plane (45º
from the trunk) (Figure 1). Orthogonal views of the humerus are obtained with internal and external rotation of
the shoulder.
Surgical Approach: Antero-Lateral
Transdeltoid MIS Approach
The skin incision is made centred on the mid portion
of the proximal humerus and runs from the lateral border of the acromion, extending 3 to 5 cm distal and lonwww.avidscience.com
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gitudinally (Figure 2A). The subcutaneous tissue layer is
then bluntly dissected to identify the avascular tendinous
raphe dividing the anterior and middle thirds of the deltoid. Splitting these tendinous fibres of the raphe avoids
further bleeding and respects the deltoid red fibres integrity throughout all the surgical procedure (Figure 2B).
The length of the deltoid splitting should not extend more
than 4 cm distally from the lateral border of the acromion
to avoid axillary nerve injuries. The subacromial and subdeltoid bursa are incised exposing the fracture site (Figure
2C and Figure 2D). At this point, the axillary nerve is always identified by palpation. The axillary nerve is identified from anterior to posterior (from distal to proximal),
attached to the inner surface of the deltoid, finishing in
the posterior third of the deltoid, where the nerve turns
in a curve coming from anterior around the neck of the
humerus. The course of the nerve is distal to the distal
end of the bursa. A skin landmark of the nerve’s path is
drawn to avoid injuries to the axillary nerve throughout
the operation and to avoid dangerous extension of the
surgical approach (Figure 3). Room enough for the plate
is created between the lateral shaft cortex and the deltoid
muscle with the nerve; this action will minimize the risk
of axillary nerve injury when placing the plate during fixation (17). This space is developed by blunt palpation with
the finger. In the case of metaphyseal fracture extension, a
long plate is needed; the distal deltoid attachment on the
humerus should be released in its anterior part to let the
plate sit correctly on the lateral shaft.
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Figure 2: Anterolateral transdeltoid MIPO approach (right shoulder):
Centred on the humeral head, extending 3-5 cm from the lateral border of the acromion (A); tendinous raphe between the anterior and
lateral thirds of the deltoid (B); subacromial bursa (C); fracture site
(D) with the LT in an anterior position, the GT in the back part, the
head in front of the surgeon, and the shaft (S) in the inferior part of
the incision.
In MIS the soft tissue envelope prevents the fragments
from further displacement; once the fragments are reduced
they remain in their reduced position as the soft tissues
avoid their displacement. Although the surgical exposure
is reduced, there is enough room to see and to make all the
manoeuvres (identifying, suturing, and reducing), as the
surgical approach is placed right at the fracture site. On
the other hand, as in any other MIS we can use the moving
windows concept and modify the surgical field: for PHF
placing the shoulder in internal rotation gives better access to the greater tuberosity; while in external rotation,
the lesser tuberosity appears in the surgical field.
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Figure 4: Fracture reduction objective: Saint Gallen´s chair with the
head (H) on top of three legs: Lesser tuberosity (LT), greater tuberosity (GT) and medial hinge (M). The chair stands on the shaft (S).
Fracture Reduction Step by Step
Figure 3: The axillary nerve´s path is mark on the skin to avoid damage throughout the operation. External jig for MIPO with a sleeve
system for percutaneous screw placing, minimizing the risk of nerve
injury.
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The objective of the reduction is to achieve the “chair
concept” given by the St. Gallen group [19,20]. The fracture
fragments (head, greater tuberosity, lesser tuberosity and
the diaphysis with the medial metaphysis) are reduced to
build a chair structure: the head is the seat and stands on
three legs, which are the greater tuberosity, lesser tuberosity and the medial metaphysis or calcar (Figure 4).This
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chair finally stands on the diaphysis to complete fracture
reduction at a second stage. Only final fragment reduction and plate fixation are done under fluoroscopy control. Fracture fragments are identified and individualized
by palpation once the bursa is incised. Preoperative planning is key at this stage: the surgical exposure is limited,
and the surgeon must know from the preoperative radiological studies (x-rays and CT-scan) where the fragments
are located. The quality of the reduction accomplished
through a MIS approach can be almost anatomical.
to relax the rotator cuff. A simple Farabeuf retracts lightly
the anterior rim of the approach. One suture goes through
the supraspinatus pulling the fracture GT fragment downwards and anteriorly to reduce the fragment (Figure 6b).
A second suture goes through the infraspinatus and teres
minor pulling lateral and anteriorly. Only one suture is
needed if the GT consists on one fragment, pulling lateral and anteriorlyto reduce the fragment. This suture will
come out from the wound and lay anterior.
Greater Tuberosity (GT) Identification and
Reduction
The GT is attached to the supraspinatus, infraspinatus
and teres minor tendons. If there is only one fragment,
the GT is displaced and located in the posterior part of
the surgical approach. In case of comminution of the GT,
fragments will be displaced according to the tendon attachments: the tip of the GT with the supraspinatus will be
superior and towards the glena; the anterior part of the GT
will be the anterior wall of the bicipital groove, and part
of the lesser tuberosity fragment; and the posterior fragments will displace posterior and medial with the infraspinatus and teres minor. Thick absorbable braided guiding
sutures are placed on the GT through the rotator cuff tendons, but not through the bone to avoid comminution of
the GT (Figure 5A). Placing this suture is technically demanding: we recommend the use of a Langebeck retractor
on the posterior side of the surgical approach with the tip
pushing the GT adding external rotation of the shoulder
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Figure 5: Traction sutures for the tuberosities and “tuberosity window” concept. Suture from the supraspinatus and infraspinatus reducing the GT pulling to anterior (A). “Tuberosity window” between
the GT when pulled to posterior, and the LT when pulled to anterior;
the head displaced in valgus is right in front of the surgeon (B). Suture from the subscapularis reducing the LT pulling to posterior (A).
(Right shoulder).
Lesser Tuberosity (LT) Identification and
Reduction
The LT is attached to the subscapularis tendon and it
is located anterior and medial in the surgical approach.
The fragment usually involves the bicipital groove and
the anterior aspect of the GT. Only one thick absorbable
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suture is needed through the subscapularis tendon. This
is done in external rotation of the shoulder and with the
Langebeck retractor in the anterior rim of the approach
with its tip pressing the LT. Reduction is obtained pulling lateral and posterior from the suture. This suture will
come out from the wound and lay posterior (Figure 5C).
In the case the long part of the biceps tendon (LHBT) is in
the fracture site, the LT and the shaft might be unreducible: the LHBT should be identified underneath the subscapularis tendon between the head fragment and medial
metaphysis and passed over (anterior) the traction suture
of the LT (Figure 7A). The tuberosities traction sutures
can be passed through the plate suture holes as a tension
band or tied to each other at the end of the procedure.
Humeral Head and Joint Surface Reduction:
“Tuberosity Window”
The suture showing the LT is pulled anteriorly through
the surgical wound. The suture attached to the GT is pulled
posteriorly and inferiorly. The result of this manoeuvre is
the exposure of the head (Figure 5B). In medial (varus)
head displacement the lateral cancellous bone side of the
fractured head fragment will appear in front of us; or the
head cartilage surface in valgus displacement. This is what
we have called the “tuberosity window”. Through this “tuberosity window” the head can be manipulated in order to
achieve its reduction from valgus (lateral), varus (medial),
posterior or anterior displacement. Different surgical tools
(i.e. periostal elevator) in the medial hinge can help reducing the head displaced in varus (Figure 6c). The glenoid
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joint surface might help reducing the head: the head in
valgus can be pushed against the glenoid with the thumb.
The head is contained by the rotator cuff avoiding anterior, superior or posterior displacement; and inferiorly by
the capsule. The head fragment might be compacted with
the shaft, and no clear fracture line can be seen. In these
cases, we recommend to create a new line, with an osteotome, giving as much bone stock as possible to the head,
for a later better fixation with the screws. Care should be
taken not to reach the medial hinge with the osteotome to
preserve the third leg of the St. Gallen´s chair; and it may
work as a fulcrum.
Once the head is reduced, the GT is pulled anteriorly and downwards and the LT posteriorly, closing the
“tuberosity window” and obtaining a 2-part fracture: the
proximal humeral segment (the Saint Gallen’s chair: the
proximal humerus with the head and tuberosities in their
places) and the diaphysis (Figure 6d). Rarely, frozen heterologous cancellous bone graft can be used in osteoporotic
cases with poor bone stock in the humeral head and metaphysis to give physical support to the humeral head. We
only use structural cancellous bone graft in comminuted
fractures to give support to the head, if it is not held by “the
legs of the chair”. When intra-articular or head split fractures are present, the displacement of each fragment must
be carefully address preoperatively. Each fragment should
be reduced independently using the same manoeuvres as
described before. At least one of the fragments of the head
includes one tuberosity which might help in the reduction.
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Figure 7: The shaft remains displaced to medial due to the interposition of the LHBT (A-B). Shaft reduction is achieved by traction from
the elbow and pulling lateral from the axilla (C-D).
Shaft Reduction
Figure 6: Reduction and fixation intraoperative X-ray images. A four
fragment fracture with lateral impaction of the head (a). GT reduction with a traction suture pulling in a lateral and anterior direction
(b). Head reduction manoeuvre against the glenoid surface with an
osteotome, trying to preserve as much bone stock in the head as possible (c). Proximal humerus reduction building the St. Gallen’s chair
(d). Shaft reduction with traction from the elbow and lateral displacement; the chair sits on the shaft (e). Temporary fixation with two Kwires through the external aiming device (f). Shaft screws and cannulated head screws over K-wires (g). Avoid screw joint penetration
checking k-wire and screw positions in internal and external rotation
(h). Final PHF fixation with a MIPO technique (i).
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Once there is a 2-part fracture, the shaft is reduced
towards the proximal humeral segment (the chair is
placed on top of the diaphysis): a periostal elevator placed
through the fracture site at the surgical neck can distract
the diaphysis and then pulling from the hanging elbow
achieve the 2-part fracture reduction (Figure 6e). If the
medial hinge of the metaphysis is displaced medially, a
gentle lateral traction from the axilla is done (Figure 7C
and Figure 7D). A Hofman (pointed) retractor inside the
shaft might help pulling the shaft lateral (Figure 7C). If
the medial hinge is displaced laterally, usually impaction
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and shortening occurs; but we do not recommend reduction with traction due to the gap that will be created. On
the opposite, bone contact will secure fracture healing and
shortening (2 cm the most) will not significantly affect
shoulder function [21].
Intraoperative X-ray
Intraoperative X-ray is used at this point to check
the accuracy of the reduction and to make the fine adjustments for an anatomical reduction. The fracture can
be temporarily fixed with K-wires and checked with an
image intensifier; we found this could make the correct
placement of the plate more difficult. The sutures from the
rotator cuff tendons control and help to maintain the reduction of the tuberosities; the head reduction is kept by
the tuberosities and the St. Gallen chair construction; plus,
the soft tissue envelope holds the fracture fragments while
plating. We use only 2 K-wires through the plate and the
external aiming device asprovisional fixation (Figure 6f).
Fracture Fixation MIPO
For definitive fracture fixation we recommend the use
of a polyaxial locking plate with non-thread head screws
(cancellous or cortical) that can be locked afterwards with
a cup system. This plate system should have an external
aiming devise for a MIPO technique. Locking plates help
to build a stable fixation in osteoporotic bone to allow
early movement. The polyaxial screws allows for correct
screw placing where there is more bone stock for better
bone purchase (14). Guide sleeves are useful for secure
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screw placing in a percutaneous way (Figure 3). The final
construction will have locking screws in divergent directions, giving enough stability for early recovery of shoulder motion with the ability to maintain the reduction until
bone healing (Figure 6f-6i).
Getting the Plate in: Shaft Reduction and
Temporarily Fixation
We get the plate in with its distal end sliding over the
lateral cortex to avoid entrapping the axillary nerve between the plate and the shaft. The correct height position
of the plate is 1 cm distal to the tip of the GT (Figure 6f).
The distance between the acromion and the plate should
be checked directly in the wound to avoid later subacromial impingement. The plate sits over the GT, centred on
the proximal humerus. Traction sutures from the tuberosities stay proximal to the plate.
One K-wire is placed in the head through the aiming
device, the plate and the GT. The height of the plate is correct if this K-wire is in the head´s midline. Shaft reduction
is obtained by pulling from the elbow downwards and lateral from the axilla at the same time (Figure 7C-7D). Be
aware to check the shaft can be moved lateral (reduced)
from the proximal humerus before placing the k-wire in
the shaft. This slight lateral movement and final reduction
of the medial hinge will be obtained with the first screw
in the shaft. We close the frame between the plate and the
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tal hole of the plate while reducing the shaft (Figure 6f).
The plate sits centred on the lateral shaft cortex if we feel
two cortices with the K-wire.
Medial Metaphyseal Hinge Final Reduction
and Shaft Fixation
Stable shaft fixation requires three bicortical screws.
Fixation starts with the most proximal screw in the shaft.
This is a traction cannulated screw. The K-wire that will
guide the screw should pass two cortices; this will tell us
the plate sits in the centre of the lateral cortex of the shaft
without taking an X-ray. Once the non-threaded head of
the screw reaches the plate, the traction effect starts pulling from the shaft against the plate when it is a medially
displaced, thus reducing the medial metaphyseal hinge
(Figure 8A and Figure 8B).When the reduction is obtained, the first screw is locked with the cup. A second
screw right distal to the first one is placed in the same way,
without traction effect. The second screw is locked with
the cup right when it reaches the plate. The third screw is
the last screw placed before removing the aiming device
(Figure 6g).
lag and compression effect can be achieved by the locking
screws due to the specific cup-locking mechanism. The
aiming device will give fixed directions for the screws; if
there is no good bone purchase, the screws can be placed
in a polyaxial mode (without the external jig): with a free
hand technique through the wound, a 30º polyaxiality is
usually allowed, depending on the plate system used (Figure 6g-6i).The screws will be driventowards good bone
stock locations for a better fixation. Polyaxiality is very
helpful in head split fractures to drive the screws to both
head fragments.
Proximal Humerus Fixation
The plate correct position is right over the GT. When
traction is made with the most proximal shaft screw, the
collateral effect is the fixation of the GT as it is compressed
between the plate and the head. The cancellous screws going to the head will fix the GT and the head. Still, some
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Figure 8: Lag screw for final medial metaphysis and shaft reduction.
This screw is the most proximal in the shaft. A: medial metaphysis is
displaced medial. B: The lag screw (most proximal screw in the shaft)
pulls the shaft reducing the medial hinge.
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The most frequent complication in plating fixation
of PHF (open or MIPO) is screw joint penetration in the
humeral head (6). To avoid this complication, we recommend the use of cannulated screws over thin K-wires:
the K-wire is drilled only in the lateral cortex and then
is gently pushed into the head cancellous bone, stopping
at the subchondral hard bone. The position of the K-wire
is checked in neutral rotation, and maximal external and
internal rotation (Figure 6h); if the position of the K-wire
is not correct or it is loose, we replace it in a polyaxial way:
looking for a location with enough bone stock to obtain
strong bone purchase. By doing so, the incidence of joint
penetration is almost 0%; and if any screw penetrates, it
is in the periphery of the head with low incidence on the
joint movement. All the plate systems place between five
and six locking screws in the head, to give enough stability
for early motion.
Final Fixation of the Tuberosities with Sutures
The GT is compressed between the plate and the head
and fixed by the head screws. If this is not enough and
there are still fragments of the GT pulled by the rotator
cuff tendons, we can use sutures going through holes in
the plate that will definitively reduce and fix these comminution fragments. Wire cerclage may also be used. The
LT is more unlikely to be fixed by screws unless it is linked
with a head fragment. LT fixation is secured with sutures
going through the plate or tied with the traction sutures
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coming from the GT. It is not possible through a MIS approach to place isolated screws to fix the LT. If there is
a rotator cuff rupture associated to the fracture, it might
be repaired at this moment. These techniques avoid further greater tuberosity displacement, impingement, and
secondary supraspinatus insufficiency (video link: https://
youtu.be/T4o_a8_9R0A).
Wound Closure
No drainage is needed; and the deltoid gap is sutured
loose, without muscle fibre compression. The arm is
placed in a sling.
RHB Protocol
Passive range of motion exercises are started on the
first day after surgery, depending on pain and activity
level. Small blood loss occurs during this type surgery. Patients are discharged home on the first or second day after
surgery with the upper limb resting on a sling over the
clothes. For active exercises, patients are allowed to dress,
wash and feed themselves right from the very beginning.
Carrying weights (more than 500 gr) is not permitted. For
better comfort, the patient’s arm is placed on a sling for a
maximum of two-three weeks. Afterwards, patients have
individualised postoperative management. But as a guide,
active range of motion is allowed four weeks after the
operation or as soon it can be done pain free with active
assisted physiotherapy; carrying weights is allowed only
when the tuberosities are healed.
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Complications
Many complications can occur in the treatment of
PHF with locking plates via MIS. These complications are
due to poor surgical technique and mistakes. The surgical technique description given in this chapter will help
us avoiding these complications, improving the final functional results and minimizing the learning curve damage.
Many of them have been already explained but we outline
the most important:
• Injury to the axillary nerve can be prevented by
preparing the subdeltoid space for the plate, identifying the nerve, and using all the guide sleeves.
In all plate systems there is a hole for a metaphyseal screw, right where the axillary nerve is located: nerve place this screw in a percutaneous way
as the potential risk of injury to the axillary nerve
is very high. We didn’t experience any acute injury of the axillary nerve in 155 cases. Barco et al,
also reported no cases of axillary nerve injury in
23 cases [15]. In other series the rate of axillary
nerve injury with MIPO techniques varies from
2.2-4% [22-26]. In young patients with a powerful and bulky deltoid muscle, the nerve might
be compressed between the plate and the deltoid
muscle. In these cases, chronic irritation of the
axillary nerve may appear a few months after the
operation. The symptoms are: anterior third del-
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toid atrophy with altered electromyography, but
not pain and full range of movement. The axillary
nerve recovers without consequences after plate
removal. Some studies report electrophysiological
changes of the axillary nerve and deltoid muscle
after MIS in PHF, but did not relate to deltoid or
functional impairment [26].
• Screw joint penetration is the most frequent complication. The main risk factor is intraoperative
screw perforation of the humeral articular surface
or loss of reduction, because of a poor “chair” construction or poor bone quality. With the tips given in the proximal humerus fixation section the
complications rate decreases dramatically [27].
• Fracture displacement can be prevented by achieving an accurate anatomical reduction (St. Gallen’s
chair concept), correct positioning of the plate
and the screws where there is more bone stock,
and firmly fixing the tuberosities to the plate [27].
Conclusion
It is possible to achieve a good anatomical reduction
through an anterolateral transdeltoid MIS in the treatment
of PHF. The main objective of the reduction is to build a
chair (the Saint Gallen’s chair concept); and the aim of the
plate is to maintain this construction until complete fracture healing. It is also possible to build a reliable fixation
through this MIS approach. The osteosynthesis obtained
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with a polyaxial locking plate is stable enough to keep the
reduction until fracture healing is achieved and to start
physiotherapy right after surgery. Satisfactory functional
results for this procedure can be obtained even in 3-4 part
PHF and osteoporosis with the potential benefits of MIS.
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