The Hertel classification can’t predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach

Cruz, Márcio Alves; Mouraria, Guilherme Grisi; Kikuta, Fernando Kenji; Zogbi, Daniel Romano; Coelho, Sérgio de Paula; Etchebehere, Maurício

doi:10.1016/j.clinsp.2023.100173

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Original articles • Clinics 78 • 2023 • https://doi.org/10.1016/j.clinsp.2023.100173 copy

The Hertel classification can’t predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background:

Proximal humeral fractures can progress to osteonecrosis of the humeral head. Hertel developed a binary classification system (12 subtypes) and demonstrated that some patterns have more risk to develop osteonecrosis. Hertel described the prevalence and the risk factors for Humeral head osteonecrosis after osteosynthesis using a Deltopectoral approach. Few studies have evaluated the prevalence and the capacity of Hertel’s classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach. The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk of developing osteonecrosis and its prevalence after osteosynthesis using the anterolateral approach.

Methods:

This was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach. Patients were divided into two groups: high risk for necrosis (group 1) and low risk for necrosis (group 2) according to Hertel’s criteria. The overall prevalence of osteonecrosis and the prevalence in each group were calculated. A radiological examination was performed in the true anteroposterior (Grashey), scapular, and axillary views, before and after the operation (minimum 1 year after surgery). A KaplanMeier curve was used to assess the pattern of the temporal evolution of osteonecrosis. The groups were compared using the Chi-square test or Fisher’s exact test. The unpaired t-test (parametric variables - age) and the MannWhitney test (non-parametric time between trauma and surgery) were used.

Results:

In total, 39 patients were evaluated. The postoperative follow-up time was 14.5 ± 3.3 months. The time to onset of necrosis was 14.1 ± 3.9 months. Sex, age, and time between trauma and surgery did not influence the risk of necrosis. Type 2, 9, 10, 11, and 12, or fractures with posteromedial head extension less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, as well as grouping did not influence the risk for osteonecrosis.

Conclusions:

Hertel’s criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach. The total prevalence of osteonecrosis was 17.9% with a tendency toward an increased incidence after 1 year of surgical treatment.

Keywords:
Shoulder fracture; Osteonecrosis

HIGHLIGHTS

Proximal humeral fractures can progress to humeral head osteonecrosis

It’s controversial if the Hertel classification can predict humeral head osteonecrosis.

Proximal Humeral Fractures can be fixed through the anterolateral approach.

Objective: to correlate the Hertel’s predictors with the humeral head osteonecrosis.

Hertel’s criteria were not able to predict the risk for humeral head osteonecrosis.

The overall prevalence humeral head osteonecrosis was 17.9%.

Variable	Value
Age (average ± SD), years	58.4 ± 12.0
Sex, n (%)
Female	22 (56.4%)
Male	17 (43.6%)
Trauma-to-surgery days (average ± SD)	6.6 ± 4.4
Follow-up (average ± SD), months	14.5 ± 3.4

Hertel’s criteria	Kappa	p-value
Medial extension^a a Fracture extension to head smaller than 8 mm.	0.04	0.60
Medial hinge loss	0.79	<0.001
Binary classification	0.62	<0.001
High-risk group^b b Risk of necrosis.	0.89	<0.001

Variable	Presence of osteonecrosis	Absence of osteonecrosis	p-value
Trauma Energy, n (%)			1.00^a a Fisher’s exact test.
High	2 (5.1%)	10 (25.6%)
Low	5 (12.8%)	22 (56.7%)
Sex, n (%)			0.20^a a Fisher’s exact test.
Female	2 (5.1%)	20 (51.2%)
Male	5 (12.8%)	12 (30.7%)
Age (average/SD)	53.8 ± 17.7	59.4 ± 11.3	0.27^b b Student’s t-test. cMann-Whitney U test (in days).
Trauma-to-surgery (Median/min -max), days	8 (1-18)	6 (1-16)	1.0^a a Fisher’s exact test.

Binary pattern	Presence of osteonecrosis (n)	Absence of osteonecrosis (n)	p-value^a a Fisher’s exact test; (n) total number of patients.
1	1	11	0.40
7	1	8	1.00
8	1	1	0.33
12	4	12	0.41

Variable	Presence of osteonecrosis	Absence of osteonecrosis	p-value
Medial hinge lesion, n(%)			0.69^a a Fisher’s exact test; (n) total number of patients.
No	3 (7.7%)	17 (43.6%)
Yes	4 (10.3%)	15 (38.4%)
Head extension <8 mm, n (%)			0.52^a a Fisher’s exact test; (n) total number of patients.
No	5 (12.8%)	25 (64.1%)
Yes	2 (5.1%)	7 (18%)

Group	Presence of osteonecrosis, n(%)	Absence of osteonecrosis, n(%)	p-value^a a Fisher’s exact test; (n) total number of patients.
Group 1	5 (12.8%)	19 (48.7%)
Group 2	2 (5.1%)	13 (33.3%)	0.68
Total	7 (17.9%)	32 (82.1%)

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[1] *Corresponding author. E-mail address:mouraria@unicamp.br (G.G. Mouraria).