A Modified Upper Anterior Acromial Approach For The Treatment Of Proximal Humeral Fractures

Background Proximal humeral fractures affect older people be much[1]. Operative interventions are usually used for unstable fractures, including open reduction and internal fixation(ORIF), tension band wiring, suture fixation, intramedullary nailing and hemi-arthroplasty, amongst which the deltoid-split approach and deltopectoral approach are commonly applied. When deltopectoral approach is adopted, the soft tissue is greatly damaged and part of the deltoid needs to be severed, which usually causes the deficiency of shoulder anteflexion.Accordingly, the risk of axillary nerve and anterior circumflex humeral artery injuries may be caused. Adopting deltoid-split approach can decrease the aforementioned risk, but it is hard to handle complicated fracture types such as three parts fractures and four parts fractures in Neer classification. Therefore, to search new approach and advance surgical technique, decrease degree of surgical injury, and improve postoperative function, has been the goal of orthopedic surgeons.Objective To investigate the advancements of upper anterior acromial approach used for proximal humeral fractures comparing with traditional approaches, and to observe the outcome of fracture healing and postoperative function of affected limbs.Methods 72 proximal humeral fracture patients(mean65.1, range: 43 to 78) were analyzed retrospectively, including 28 male and 44 female, and underwent surgical interventions 3 to 10 days after initial injury. All the patients were divided into three groups randomly. Advanced upper anterior acromial approach was adopted in group A, deltoid-split approach in group B and deltopectoral approach in group C. All the patients involved underwent open reduction and fixed plate fixation. The operation time duration, intraoperative bleeding volume and amount of postoperative drainage were documented. Visual analogue scale was recorded one week and 3 months postoperatively. Constan-Murley scale was recorded 3, 6 and 12 months postoperatively. All the values were recorded as x ±s and analyzed with SNK(Student-Newman-Keuls)-q test. The difference was considered significant at a value of p<0.05. All the patients got anatomical reduction or approximate anatomical reduction, and all the incision got stage-Ⅰhealing after the operation. The patients were available for follow-up at a mean of 13 months(6 to 24 months). The mean operation time of group A(advanced upper anterior acromial approach) was(110.4±10.1 minutes), which showed no statistically difference with that(110.7±9.8 minutes) of group B(deltoid-split approach)(P>0.05). The mean operation time of group A and B was longer than that(85.3±4.4 minutes) of group C(deltopectoral approach)(P<0.05). The mean intraoperative bleeding volume(192.9±33.4 ml) and the mean amount of postoperative drainage(49.5±6.5 ml) of group A were significantly lower than those(407.7±70.7 and 111.5±18.2 mlrespectively) of group C(P<0.05), which had no statistical difference with those(190.9±33.8 and 50.2±8.5 ml respectively) of group B(P>0.05). One week after surgery, the mean VAS scale(4.5±0.6) of group A was lower than that of group C(6.2±0.8)(P<0.05),which had no statistical difference with that of group B(4.9±0.6)(P>0.05). The mean VAS scale of all the groups showed no difference statistically with each other preoperatively and 3 months postoperatively(P>0.05). Three months after surgery, the mean Constan-Murley scale(54.2±2.5) of group A was higher than that of group C(41.5±6.7)(P<0.05), which had no statistical difference with that of group B(54.6±3.1)(P>0.05). The mean Constan-Murley scale of all the groups showed no difference statistically with each other 6 months and 12 months postoperatively(P>0.05). Three months postoperatively, the fracture healing percentage of group C(86.11%) was higher than that of group A(46.15%)(P<0.0125), which had no statistical difference with that of group B(90.91%)(P>0.0125). One patient in group C was diagnosed as four parts proximal humeral fracture, who underwent with arthroplasty by extending the approach.Conclusion Adopting advanced upper anterior acromial approach for the treatment of proximal humeral fracture can decrease intraoperative bleeding volume and amount of postoperative drainage, which can also get higher visual analogue scale and Constan-Murley scale comparing with traditional approach. Besides, orthopedic surgeons can easily extend this approach for humeral arthroplasty. It is an ideal operative approach for proximal humeral fractures.