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

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 copiar

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

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Objetivo:

As vias de acesso anterolaterais para a osteossíntese do úmero proximal permitem a exposição direta do aspecto lateral do úmero sem necessitar das retrações musculares da via deltopeitoral. Contudo, há grande preocupação com a possibilidade de lesão iatrogênica do nervo axilar e consequente piora no resultado funcional pós-operatório. Identificar a incidência de lesões iatrogênicas do nervo axilar e avaliar os resultados funcionais da osteossíntese do úmero proximal com placas bloqueadas, utilizando as vias anterolaterais.

Métodos:

Revisão da literatura seguindo o protocolo PRISMA.

Resultados:

Foram selecionados 23 artigos do total de 786 indivíduos submetidos às vias de acesso anterolaterais. Foram confirmados 3 casos (0,38%) de lesões iatrogênicas do nervo axilar. Os resultados dos testes funcionais foram semelhantes aos da via deltopeitoral.

Conclusão:

As vias de acesso anterolaterais são uma alternativa viável e segura para a osteossíntese do úmero proximal com placas bloqueadas. Nível de Evidência II, Revisão Sistemática.

Descritores:
Fixação interna de fraturas; fraturas do úmero proximal; complicações; cirurgia

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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