The benefits of intramedullary osteosynthesis in proximal humerus fractures

Relevance. Proximal humerus fractures constitute 5 to 6% of all fractures in adults and are the third most common osteoporotic fracture. Advanced surgical techniques, accumulated knowledge and practical experience, as well as new evolving implants have expanded the indications for surgical treatment. Dedicated studies, however, fail to outline any superior and convincingly outperforming surgical treatment option.

The objective is to find out most optimal treatment options by comparing the results in patients with proximal humerus fractures who underwent either blocked intramedullary osteosynthesis (BIOS) or osteosynthesis with precontoured angular stable LCP humerus plates (LCP).

Methods. The study included 534 patients with proximal humerus fractures who underwent surgical reconstruction between 2015 and 2024, including 503 (94.2%) patients undergoing BIOS and 31 (5.8%) patients undergoing open LCP repositioning.

Results and discussion. The treatment results were assessed in 173 (32.4 %) patients. The postoperative follow-up did not exceed 8 months. BIOS technique allowed to achieve favorable results in terms of absence of pain, restored joint function and scope of movement, as well as low re-operation rate. LCP osteosynthesis showed a slightly poorer performance for all the studies parameters.

Conclusion. Blocked intramedullary osteosynthesis is a safe and efficient treatment option in proximal humerus fractures, associated with reliable stabilization, minimized tissue trauma, intact blood supply, low risk of postoperative wound infection, decreased operation time, and early rehabilitation without complications. However, the use of intramedullary pins is not a ‘one-size-fit-all’ treatment strategy. The treatment decision should be supported by advanced diagnostics, taking into account the type of fracture, bone tissue quality and concomitant pathologies, as well as patient’s individual characteristics and expectations.

1. Aleksanin S.S., Evdokimov V.I., Rybnikov V.Ju. Znachenija pokazatelej kostno-myshechnoj sistemy i soedinitel’noj tkani dlja sostojanija zdorov’ja lichnogo sostava Federal’noj protivopozharnoj sluzhby Gosudarstvennoj protivopozharnoj sluzhby MChS Rossii [Significance of musculoskeletal and connective tissue parameters as health indicators in Federal Fire-Fightg ing Service officers of the State Fire-Fighting Service of the EMERCOM of Russia]. Mediko-biologicheskie i social’no-psihologicheskie problemy bezopasnosti v chrezvychajnyh situacijah [Medicо-Biological and Socio-Psychological Problems Safety in Emergency Situations]. 2022; 4:(5–30). DOI: 10.25016/2541-7487-2022-0-4-05-30. (In Russ.)

2. Gudz’ Yu.V., Vetoshkin A.A., Evdokimov V.I. [et al.]. Analiz okazaniya spetsializirovannoi i vysokotekhnologicheskoi po moshchi sotrudnikam Federal’noi protivopozharnoi sluzhby MChS Rossii v otdele travmatologii i ortopedii Vserossiiskogo tsen tra ekstrennoi i radiatsionnoi meditsiny im. A.M. Nikiforova [Specialized and high-tech assistance to the Federal Fire-Fightin Service staff of the EMERCOM of Russia providedat the Department of Traumatology and Orthopedics at the Nikiforov Center of Emergency and Radiation Medicine]. Mnogoprofil’naya klinika XXI veka. Innovatsii i peredovoi opyt [Multidisciplinary clinical care of 21st century. Innovations and advanced experience]: Research Conference Proceedings. St. Petersburg. 2022: 36–38. (In Russ.)

3. Evdokimov V.I., Bobrinev E.V., Vetoshkin A.A., Kondashov A.A. Struktura nozologij i riski razvitija proizvodstven nogo travmatizma u lichnogo sostava Federal’noj protivopozharnoj sluzhby MChS Rossii (2012–2021 gg.) [The composi tion of nosologies and occupational injury risks in officers of the Federal Fire Service of the Ministry of Emergency Situa tions of Russia (2012–2021)]. Mediko-biologicheskie i social’no-psihologicheskie problemy bezopasnosti v chrezvychajnyh situacijah [Medicо-Biological and Socio-Psychological Problems of Safety in Emergency Situations]. 2023; (1):13–41 DOI: 10.25016/2541-7487-2023-0-1-13-41. (In Russ)

4. Evdokimov V.I., Sivashhenko P.P., Hominec V.V., Vetoshkin A.A., Ivanov V.V. Mediko-statisticheskie pokazateli travma tizma voennosluzhashhih Vooruzhennyh sil Rossijskoj Federacii (2003–2019 gg.) [Medical and statistical trauma incidence rate indicators in the military of the Armed Forces of the Russian Federation (2003-2019)]. St. Petersburg. 2021. 210 p. (Serija «Zabolevaemost’ voennosluzhashhih» ; vyp. 15 [Series: Disease incidence among the military]). (In Russ.)

5. Kogan P.G., Voroncova T.N., Shubnjakov I.I. [et al.]. Jevoljucija lechenija perelomov proksimal’nogo otdela plechevoj kosti (obzor literatury) [Evolution of treatment of the proximal humerus fractures (review)]. Travmatologija i ortopedija Rossii [Traumatology and orthopedics of Russia]. 2012; (3):154–161. (In Russ.)

6. Li D.H., Neviaser R.Dzh. Hirurgija plecha i loktja. Operativnaja tehnika [Shoulder and elbow surgery. Surgical interven tion technique]. Moscow. 2021. 796 p. (In Russ.)

7. Norkin I.A., Barabash Ju.A., Kireev S.I. [et al.]. Perelom na urovne plechevogo pojasa i plecha : klinicheskie rekomenda cii [Shoulder girdle and shoulder fractures: clinical recommendations]. Moscow. 2021. 20 p. (In Russ.)

8. Boadi P.J., Da Silva A., Mizels J. [et al.]. Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations. JSES. Rev. Rep. Tech. 2024 ;4(3):615–624. DOI: 10.1016/j.xrrt.2024.01.001.

9. Court-Brown C.M., Garg .A, McQueen M.M. The epidemiology of proximal humeral fractures. Acta Orthop. Scand. 2001;72(4):365–371. DOI: 10.1080/000164701753542023.

10. D’Almeida S.S., Cannon R., Vu N.T. [et al.]. Comparing Intramedullary Nails and Locking Plates in Displaced Proxi mal Humerus Fracture Management: A Systematic Review and Meta-Analysis. Cureus. 2024;16(2):e54235. DOI: 10.7759/cureus.54235.

11. Dilisio M.F., Nowinski R.J., Hatzidakis A.M., Fehringer E.V. Intramedullary nailing of the proximal humerus: evolution, technique, and results. J. Shoulder. Elbow. Surg. 2016;25(5):e130–e138.

12. Frigg R. Locking Compression Plate (LCP). An osteosynthesis plate based on the Dynamic Compression Plate and the Point Contact Fixator (PC-Fix). Injury. 2001; 32(Suppl 2):63–66. DOI: 10.1016/s0020-1383(01)00127-9

13. Goyal S., Ambade R., Singh R. [et al.]. A Comprehensive Review of Proximal Humerus Fractures: From Epidemiology to Treatment Strategies. Cureus. 2024;16(4):e57691. DOI: 10.7759/cureus.57691.

14. Handoll H.H., Elliott J., Thillemann T.M. [et al.]. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022; 6(6):CD000434. DOI: 10.1002/14651858.CD000434.pub5.

15. Hohmann E., Keough N., Glatt V., Tetsworth K. Surgical treatment of proximal humerus fractures: a systematic review and meta-analysis. Eur. J. Orthop. Surg. Traumatol. 2023; 33(6):2215–2242. DOI: 10.1007/s00590-022-03436-3

16. Kannus P., Palvanen M., Niemi S. [et al.]. Rate of proximal humeral fractures in older Finnish women between 1970 and 2007. Bone. 2009; 44(4):656–659. DOI: 10.1016/j.bone.2008.12.007.

17. Karl J.W., Olson P.R., Rosenwasser M.P. The Epidemiology of Upper Extremity Fractures in the United States. 2009. J. Orthop. Trauma. 2015; 29(8):e242–e244. DOI: 10.1097/BOT.0000000000000312.

18. Konrad G., Bayer J., Hepp P. [et al.]. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique. J. Bone Joint Surg. Am. 2010; 92(Suppl 1, Pt 1):85–95.

19. Martinez-Catalan N., Boileau P. The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not. Curr. Rev. Musculoskelet Med. 2023;16(2):85–94. DOI: 10.1007/s12178-022-09816-w