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Abstract：
BACKGROUND: Proximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3-35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel\'s criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis.
METHODS: In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN.
RESULTS: HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer\'s classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN.
CONCLUSIONS: We conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN.
METHODS: Level 3, retrospective cohort study.
METHODS: In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN.
RESULTS: HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer\'s classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN.
CONCLUSIONS: We conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN.
METHODS: Level 3, retrospective cohort study.
摘要：
背景：肱骨近端骨折（PHF）很常见，在使用内部锁定钢板进行ORIF后，可导致3-35％的肱骨头坏死（HHN）。很少有研究关注这种情况，风险因素仍然是讨论的话题。赫特尔骨折后初始头部缺血的标准(骨折复杂性，内侧铰链位移和短干端头部延伸)最近与HHN相关，但是关于这个话题仍然明显缺乏证据。由于其与股骨近端解剖相似，一些作者认为，PHF也可能受益于早期手术以避免头部坏死。
方法：在这项为期10年的回顾性研究中，我们评估了来自一个中心的305例患者.所有病例均通过三角肌入路用PHILOS板治疗。平均随访时间为467天。主要终点为HHN。
结果：在12例患者（4％）中诊断为HHN，其中10例在手术后第一年内被诊断出，1例在手术后4年被诊断出。HHN与骨折类型（AO和Neer分类）呈正相关（p<0.04），初始颈轴角（NSA）和干骨干端头部延伸（MHE）。所有HHN病例均发生内侧铰链位移（MHD）。实现完美复位(<2mm位错)与避免HHN(p=0.035)相关。尽管在32％的高风险病例中出现了HHN（短MHE的四部分骨折），当达到完美还原时，它被完全避免(0%)。入院后直到手术的时间既不是HHN的保护因素，也不是HHN的危险因素。
结论：我们得出结论，骨折复杂性（四部分骨折和C型骨折）以及干phy端头部延伸小于8mm的内侧铰链破裂是肱骨头坏死的相关危险因素。这些标准的组合产生了高风险模式，HHN率为32％。虽然往往难以实现，完美还原是一个明显的保护因素，并将HHN降至0%。完美的减少可能是融合的关键，因此,肱骨头的打捞,特别是在高风险的情况下。手术时机与HHN无关。
方法：3级，回顾性队列研究。
方法：在这项为期10年的回顾性研究中，我们评估了来自一个中心的305例患者.所有病例均通过三角肌入路用PHILOS板治疗。平均随访时间为467天。主要终点为HHN。
结果：在12例患者（4％）中诊断为HHN，其中10例在手术后第一年内被诊断出，1例在手术后4年被诊断出。HHN与骨折类型（AO和Neer分类）呈正相关（p<0.04），初始颈轴角（NSA）和干骨干端头部延伸（MHE）。所有HHN病例均发生内侧铰链位移（MHD）。实现完美复位(<2mm位错)与避免HHN(p=0.035)相关。尽管在32％的高风险病例中出现了HHN（短MHE的四部分骨折），当达到完美还原时，它被完全避免(0%)。入院后直到手术的时间既不是HHN的保护因素，也不是HHN的危险因素。
结论：我们得出结论，骨折复杂性（四部分骨折和C型骨折）以及干phy端头部延伸小于8mm的内侧铰链破裂是肱骨头坏死的相关危险因素。这些标准的组合产生了高风险模式，HHN率为32％。虽然往往难以实现，完美还原是一个明显的保护因素，并将HHN降至0%。完美的减少可能是融合的关键，因此,肱骨头的打捞,特别是在高风险的情况下。手术时机与HHN无关。
方法：3级，回顾性队列研究。
