ANTEROLATERAL APPROACHES FOR PROXIMAL HUMERAL OSTEOSYNTHESIS: A SYSTEMATIC REVIEW

Mouraria, Guilherme Grisi; Zoppi, Américo; Kikuta, Fernando Kenji; Moratelli, Lucas; Cruz, Márcio Alves; Etchebehere, Maurício

doi:10.1590/1413-785220192703215572

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Acta Ortopédica Brasileira

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Systematic Review, Shoulder • Acta Ortop Bras 27 (3) • May-June 2019 • https://doi.org/10.1590/1413-785220192703215572 copy

ANTEROLATERAL APPROACHES FOR PROXIMAL HUMERAL OSTEOSYNTHESIS: A SYSTEMATIC REVIEW

VIAS DE ACESSO ANTEROLATERAIS PARA OSTEOSSÍNTESE DO ÚMERO PROXIMAL: UMA REVISÃO SISTEMÁTICA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Anterolateral approaches for proximal humerus osteosynthesis have great advantages because they allow direct exposure of the lateral aspect of the humerus without the muscular retraction seen in the deltopectoral approach. However, much resistance is found among surgeons due to the potential risk of iatrogenic injury to the axillary nerve. To identify the incidence of axillary nerve iatrogenic lesions and evaluate the functional results of proximal humerus osteosynthesis with locking plates using anterolateral approaches.

Methods:

The literature review followed the PRISMA protocol.

Results:

A total of 23 articles were selected from 786 patients submitted to anterolateral approaches. Three cases (0.38%) of iatrogenic axillary nerve lesions were confirmed. The results of the functional tests were similar to those of the deltopectoral approach.

Conclusion:

Anterolateral approaches are a viable and safe alternative for proximal humerus osteosynthesis with locking plate. Subacromial impingement was the most frequent complication. Level of Evidence II, Systematic Review.

Keywords:
Humeral Fractures; Surgery; Complications; Osteosynthesis

Author	Year	Type of study	N (^ Total number of individuals completing follow-up in the study/individuals among whom were submitted to the anterolateral approach. Retro, retrospective. )	Age	Approaches
Sohn et al.¹²12. Sohn HS, Jeon YS, Lee J, Shin SJ. Clinical comparison between open plating and minimally invasive plate osteosynthesis for displaced proximal humeral fractures: A prospective randomized controlled trial. Injury. 2017;48(6):1175–82.	2017	Prospective	90/45	64	Deltoid-split (MIPO) x Deltopectoral
Buecking et al.¹³13. Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472(5):1576–85.	2014	Prospective	90/48	69^* * Related only to the anterolateral approach;	Deltoid-split (MIPO) x Deltopectoral
Fischer et al.¹⁴14. Fischer C, Frank M, Kunz P, Tanner M, Weber MA, Moghaddam A, et al. Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures. Injury. 2016;47(8):1725–31.	2016	Retro	50/20	59.4	Deltoid-split (MIPO) x Deltopectoral
Liu et al.¹⁵15. Liu K, Liu P, Liu R, Wu X. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. Med Sci Monit. 2015;21:496–504.	2015	Retro	91/39	60.2^* * Related only to the anterolateral approach;	Deltoid-split (MIPO) x Deltopectoral
Jung et al.¹⁶16. Jung S. Indirect reduction maneuver and minimally invasive approach for displaced proximal humerus fractures in elderly patients. Clin Orthop Surg. 2013;5(1):66–73.	2013	Retro	32/32	72.4	Deltoid-split (MPO)
Martetschläger et al.¹⁷17. Martetschläger F, Siebenlist S, Weier M, Sandmann G, Ahrens P, Braun K, et al. Plating of proximal humeral fractures. Orthopedics. 2012;35(11):e1606-12.	2012	Retro	70/37	59	Deltoid-split (MIPO) x Deltopectoral
Wu et al.¹⁸18. Wu CH, Ma CH, Yeh JJH, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71(5):1364–70.	2011	Retro	60/28	58.6^* * Related only to the anterolateral approach;	Deltoid-split(MIPO)/ Extended deltoid split) x Deltopectoral
Röderer et al. ¹⁹19. Röderer G, Erhardt J, Graf M, Kinzl L, Gebhard F. Clinical results for minimally invasive locked plating of proximal humerus fractures. J Orthop Trauma. 2010;24(7):400–6.	2010	Retro	54/54	70	Deltoid-split (MIPO)
Hepp et al.²⁰20. Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H. The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. J shoulder Elb Surg. 2008;17(1):21–8.	2008	Retro	83/39	65	Deltoid-split (MIPO) x Deltopectoral
Lin et al.²¹21. Lin T, Xiao B, Ma X, Fu D, Yang S. Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures. BMC Musculoskelet Disord. 2014;15:206.	2014	Retro	86/43	63^* * Related only to the anterolateral approach;	Deloid-split (MIPO) x Deltopectoral
Falez et al.²²22. Falez F, Papalia M, Greco A, Teti A, Favetti F, Panegrossi G, et al. Minimally invasive plate osteosynthesis in proximal humeral fractures: one-year results of a prospective multicenter study. Int Orthop. 2016;40(3):579–85.	2016	Retro	74/74	68.5	Deltoid-split (MIPO)
Chen et al.²³23. Chen H, Hu X, Tang H, Yang G, Xiang M. Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS. Biomed Res Int. 2015;2015:971216.	2015	Retro	27/27	67.3	Deltoid-split (MIPO)
Koljonen et al.²⁴24. Koljonen PA, Fang C, Lau TW, Leung F, Cheung NWK. Minimally invasive plate osteosynthesis for proximal humeral fractures. J Orthop Surg (Hong Kong). 2015;23(2):160–3.	2015	Retro	40/40	63	Deltoid-split (MIPO)
Bockmann et al.²⁵25. Bockmann B, Buecking B, Franz D, Zettl R, Ruchholtz S, Mohr J. Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study. BMC Musculoskelet Disord. 2015;16:160.	2015	Retro	52/52	67	Deltoid-split (MIPO)
Oh et al.²⁶26. Oh HK, Cho DY, Choo SK, Park JW, Park KC, Lee J Il. Lessons learned from treating patients with unstable multifragmentary fractures of the proximal humerus by minimal invasive plate osteosynthesis. Arch Orthop Trauma Surg. 2015;135(2):235–42.	2015	Retro	26/26	67	Deltoid-split (MPO)
Singh et al.²⁷27. Singh H, Batra A, Patel D. Lateral transdeltoid approach to proximal humerus fractures. Int Surg J. 2015;2(3):337–40.	2015	Retro	20/20	45.9	Deltoid split (MIPO)
Imarisio et al.²⁸28. Imarisio D, Trecci A, Sabatini L, Scagnelli R. Treatment for proximal humeral fractures with percutaneous plating: Our first results. Musculoskelet Surg. 2013;97(1 Suppl):85–91.	2013	Retro	29/29	53	Deltoid-split (MIPO)
Barco et al.²⁹29. Barco R, Barrientos I, Encinas C, Antuña SA. Minimally invasive poly-axial screw plating for three-part fractures of the proximal humerus. Injury. 2012;43(Suppl 2):7–11.	2012	Retro	23/23	62	Deltoid-split MIPO
Ruchholtz et al.³⁰30. Ruchholtz S, Hauk C, Lewan U, Franz D, Kühne C, Zettl R. Minimally Invasive Polyaxial Locking Plate Fixation of Proximal Humeral Fractures: A Prospective Study. J Trauma Inj Infect Crit Care. 2011;71(6):1737–44.	2011	Retro	50/50	65.5	Deltoid-split (MIPO) x Extended deltoid split
Gavaskar et al.³¹31. Gavaskar AS, Muthukumar S, Chowdary N. Biological osteosynthesis of complex proximal humerus fractures: Surgical technique and results from a prospective single center trial. Arch Orthop Trauma Surg. 2010;130(5):667–72.	2010	Retro	15/15	43	Deltoid split (MIPO)
Laflamme et al.³²32. Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial. J Orthop Trauma. 2008;22(3):153–8	2008	Retro	27/27	64	Deltoid split (MIPO)
Gardner et al.³³33. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008;22(2):132–7.	2008	Retro	23/23	65	Extended deltoid split
Somasundaram et al.³⁴34. Somasundaram K, Huber CP, Babu V, Zadeh H. Proximal humeral fractures: The role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates. Injury. 2013;44(4):481–7.	2013	Retro	21/11	64.6	Extended deltoid split x Deltopectoral
Acklin et al.³⁵35. Acklin YP, Sommer C. Plate fixation of proximal humerus fractures using the minimally invasive anterolateral delta split approach. Oper Orthop Traumatol. 2012;24(1):61–73.	2012	Retro	29/29	64	Deltoid-split (MIPO)

Author	Year	Score / Functional evaluation	Number axillary palsy (evaluation method)
Sohn et al.¹²12. Sohn HS, Jeon YS, Lee J, Shin SJ. Clinical comparison between open plating and minimally invasive plate osteosynthesis for displaced proximal humeral fractures: A prospective randomized controlled trial. Injury. 2017;48(6):1175–82.	2017	Constant, UCLA, VAS	None (Clinical)
Buecking et al.¹³13. Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472(5):1576–85.	2014	Constant, ADL, VAS	None (Clinical)
Fischer et al.¹⁴14. Fischer C, Frank M, Kunz P, Tanner M, Weber MA, Moghaddam A, et al. Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures. Injury. 2016;47(8):1725–31.	2016	Constant, DASH, ASES, ROM,	None (ENMG)
Liu et al.¹⁵15. Liu K, Liu P, Liu R, Wu X. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. Med Sci Monit. 2015;21:496–504.	2015	Constant, DASH, ROM	None (Clinical)
Jung et al.¹⁶16. Jung S. Indirect reduction maneuver and minimally invasive approach for displaced proximal humerus fractures in elderly patients. Clin Orthop Surg. 2013;5(1):66–73.	2013	Constant, VAS, ROM, ADL	1 (ENMG)
Martetschläger et al.¹⁷17. Martetschläger F, Siebenlist S, Weier M, Sandmann G, Ahrens P, Braun K, et al. Plating of proximal humeral fractures. Orthopedics. 2012;35(11):e1606-12.	2012	Constant, ADL, ROM, ASES, DASH, Strength	None (Clinical)
Wu et al.¹⁸18. Wu CH, Ma CH, Yeh JJH, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71(5):1364–70.	2011	Constant, DASH	None (ENMG)
Röderer et al.¹⁹19. Röderer G, Erhardt J, Graf M, Kinzl L, Gebhard F. Clinical results for minimally invasive locked plating of proximal humerus fractures. J Orthop Trauma. 2010;24(7):400–6.	2010	Constant, ROM	None (Clinical)
Hepp et al.²⁰20. Hepp P, Theopold J, Voigt C, Engel T, Josten C, Lill H. The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. J shoulder Elb Surg. 2008;17(1):21–8.	2008	Constant, DASH	None (Clinical)
Lin et al.²¹21. Lin T, Xiao B, Ma X, Fu D, Yang S. Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures. BMC Musculoskelet Disord. 2014;15:206.	2014	Constant	1 (Clinical + ENMG)
Falez et al.²²22. Falez F, Papalia M, Greco A, Teti A, Favetti F, Panegrossi G, et al. Minimally invasive plate osteosynthesis in proximal humeral fractures: one-year results of a prospective multicenter study. Int Orthop. 2016;40(3):579–85.	2016	Constant	None (Clinical)
Chen et al.²³23. Chen H, Hu X, Tang H, Yang G, Xiang M. Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS. Biomed Res Int. 2015;2015:971216.	2015	Constant	None (Clinical)
Koljonen et al.²⁴24. Koljonen PA, Fang C, Lau TW, Leung F, Cheung NWK. Minimally invasive plate osteosynthesis for proximal humeral fractures. J Orthop Surg (Hong Kong). 2015;23(2):160–3.	2015	Constant, QuickDASH, ROM	None (Clinical)
Bockmann et al.²⁵25. Bockmann B, Buecking B, Franz D, Zettl R, Ruchholtz S, Mohr J. Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study. BMC Musculoskelet Disord. 2015;16:160.	2015	Constant, ADL, VAS	None (Clinical)
Oh et al.²⁶26. Oh HK, Cho DY, Choo SK, Park JW, Park KC, Lee J Il. Lessons learned from treating patients with unstable multifragmentary fractures of the proximal humerus by minimal invasive plate osteosynthesis. Arch Orthop Trauma Surg. 2015;135(2):235–42.	2015	DASH, UCLA, ROM, VAS	None (Clinical)
Singh et al.²⁷27. Singh H, Batra A, Patel D. Lateral transdeltoid approach to proximal humerus fractures. Int Surg J. 2015;2(3):337–40.	2015	Constant	None (Clinical)
Imarisio et al.²⁸28. Imarisio D, Trecci A, Sabatini L, Scagnelli R. Treatment for proximal humeral fractures with percutaneous plating: Our first results. Musculoskelet Surg. 2013;97(1 Suppl):85–91.	2013	Constant	None (Clinical)
Barco et al.²⁹29. Barco R, Barrientos I, Encinas C, Antuña SA. Minimally invasive poly-axial screw plating for three-part fractures of the proximal humerus. Injury. 2012;43(Suppl 2):7–11.	2012	Constant, DASH	None (ENMG)
Ruchholtz et al.³⁰30. Ruchholtz S, Hauk C, Lewan U, Franz D, Kühne C, Zettl R. Minimally Invasive Polyaxial Locking Plate Fixation of Proximal Humeral Fractures: A Prospective Study. J Trauma Inj Infect Crit Care. 2011;71(6):1737–44.	2011	Constant, VAS, DASH	None (Clinical)
Gavaskar et al.³¹31. Gavaskar AS, Muthukumar S, Chowdary N. Biological osteosynthesis of complex proximal humerus fractures: Surgical technique and results from a prospective single center trial. Arch Orthop Trauma Surg. 2010;130(5):667–72.	2010	Constant, ROM	None (Clinical)
Laflamme et al.³²32. Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial. J Orthop Trauma. 2008;22(3):153–8	2008	Constant, DASH	None (Clinical)
Gardner et al.³³33. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008;22(2):132–7.	2008	Quick-DASH, ROM	None (Clinical)
Somasundaram et al.³⁴34. Somasundaram K, Huber CP, Babu V, Zadeh H. Proximal humeral fractures: The role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates. Injury. 2013;44(4):481–7.	2013	Constant, DASH	None (Clinical)
Acklin et al.³⁵35. Acklin YP, Sommer C. Plate fixation of proximal humerus fractures using the minimally invasive anterolateral delta split approach. Oper Orthop Traumatol. 2012;24(1):61–73.	2012	Constant	1 (Clinical)

Complication	Variation	Average	Number of articles that did not seek complications
Head implant loosening	0–8 %	3.32%	5
Infection	0–8%	1.4%	6
Screw perforation	0–12%	2.7%	5
Osteonecrosis	0–6%	0.8%	0
Impingement	0–25%	4.8%	6
Malreduction	0–10%	6.6%	1
Non-union	0–15%	1.36%	2

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