Design And Clinical Application Of Proximal Humerus Memory Connector

Sun jianwei* ,Zhang Chuncai, Xu Shuogui

* Department of orthopaedics, Changhai Hospital, Shanghai, China200433
Address for Correspondence:
Sun jianwei
Department of orthopaedics,
Changhai Hospital, Shanghai, China200433

Abstract:
To research a new method to treat the fracture and nonunion of the region from anatomical
neck to the diaphysis part of the proximal humerus. According to the mechanical character of
bio memory material Nitional and the physiological character of proximal humerus, a new
device called proximal humerus memory connector was designed. 22 cases of comminuted
fracture, malunion and nonunion of proximal humerus were treated by this device. The healing
style was characterized by plate bone substitution, no disordering callus was observed. The
function of the shoulder was scored average 88.5 according to the criteria of Michael Reese.
PHMC is an efficacious method to treat every type fractures and nonunion of the region from
anatomical neck to the diaphysis part of humerus, and a new way is explored to reduce the rate
of prostheses displacement of this part.
Keywords: Humeral fractures; Shoulder fractures; Proximal humerus memory connector
J.Orthopaedics 2007;4(2)e38

Introduction:
The 4-5% of all the fracture is the fracture of proximal humerus [1-2].For dislocated
comminuted fracture of proximal humerus , the steel plate and bolt system made of the
austenitic material sometimes is difficult to find point of resistance force in order to maintain
restitution and fixation effectively,and furthermore the ununited fracture and ischemic necrosis
of caput humeralis are common[1,3]. Conservative treatment often leads to pain and different
degrees of disability because of metachoresis and compareed long-term external fixation[4,5]
So the reports of the prosthetic replacement are seen frequently[6]. Owing to this, the author
invents the proximal humerus memory connector(PHMC),according to the characteristic of the
nitinol alloy [7]and the anatomic figure of proximal humerus .from August 2000 to September
2003, total 22 cases of fracture malunion and ununited fracture of proximal humerus had been

treated by PHMC. Now we reports as follow.

Design,principle and application
The Structure Design
According to the anatomic and biomechanical features of proximal humerus, choosing 2 to
2.5mm thickness nickel 50at%~53at% nitinol plate, the PHMC is designed to consist of head
part, axial compression part and body part(see fig.1). The head part consists of directing fixing
branch for caput
humeralis and humerus semiring holding branch for anatomical neck. The holding plate and
holding wing compose body part.It is treated to have one way memory effect and recovery
temperature is 332. According to the fracture type, The PHMC is designs to typeand
type .Each type consists of different sizes.
The Principle
The head body and compression part are deformated in low temperature to fit the figure of
operation region on proximal humerus.The metallography of PHMC is changed by body
temperature,which leads to mechanics proceeding. (1) Directing fixing branch and semiring
holding branch stabilize disclosed caput humeralis. (2) The standard body part will hold the
non-standard tubular bone on with multipoint fixation. The hooks of axial compression parts
will be inserted into the holes on two side of the fracture. (3)The directing fixing branch and
compression branch which are restricted by the bone hole when reverting to their original
shapes exert continuously memory compressure at the fracture line. Because of above
mentioned 3 reasons, PHMC and two ends will compose 3D mnemonic fixation.
The Method of Application
According to the type,of fracture, the type and size of PHMC are decided before operation.
General anaesthesia or block anaesthesia of brachiplex is applyed. Semirecumbent position is
taken . Anteriomedial approach of shoulder is chosed . The incision can be extended to
acromial process if necessary. The incision to ilium is prepared.
(1)The fracture of greater tubercle lesser tubercle and surgical neck oranatomical
neck of humerus. The fracture site is explored ,a bone channel which diameter is 0.4-0.6 cm
is drilled on the site 0.5-1.0 cm below the tip of greater tuberosity of humerus, casting shadow
to the center of caput humeralis and not piercing through articular facet. And then the directing
fixing branch of the PHMC is inserted into the channel. The points for semiring holding branch
inserting are determined, the pores are drilled ,and then the branches are inserted into the pores.
The head part of PHMC is rewarmed. And then, the body part of PHMC is inserted, the
holding wings fix the distal end of fracture, and PHMC is rewarmed. At last, the points for
axial compression part which is plastic formed and expanded are determined , the pores are
drilled ,and then the part is inserted into the pores. The part is rewarmed. So the whole fixation

is completed.
(2) The nonunion of surgery neck of humerus. The scar and free bone sequestrum are
removed to expose the cancellated bone of the proximal end of the nonunion. The medullary
cavity of distal end is drilled through. Then the PHMC is applyed. At last, the holding wing of
PHMC is cooled and spread out of bone. The iliac grafting bone composed of cancellated bone
and cortical bone is put into the space between bone and PHMC, which spanned the fracture
site like splints. The cancellated bone is towards the nonunion while the cortical bone is
towards the PHMC. Finally, PHMC is rewarmed and fixes the nonunion.The spatium between
PHMC and bone is filled with scum of spongy bone.
(3) The serious comminuted fracture or compressed defection of greatertubercle lesser
tubercle and surgical neck of humerus. The large surface of iliac bone graft is taken to
contact the cancellated bone of cancellated bone ,while the small end of the graft is inserted
into the medullary cavity of distal diaphysis.
(4) The serious comminuted fracture or compressed defection of greatertubercle lesser
tubercle and surgical neck and comminuted fracture of proximal
1/3 diaphysis of humerus. At first comminuted fracture of diaphysis is reduced and fixed by
arched toothed nails from far distally to proximum; The subsequent processes are applyed
according to above (3) (1).
(5) The articular capsule and rotator cuff can be tied to the semiring holding branch for
anatomical neck of humerus.
Postoperative Management
(1) Drainage. A drainage will be retained for 24~48h in cases of fractures and nonunion.
(2) stopping. Suspension with triangular bandage for one week generally.
(3) Functional exercise. About 2 days after operation, the patient should begin to contract the
muscle group of upper arm actively and gradually.And about 2 weeks after operation, the
patient should begin to flex or extend the shoulder actively and gradually.
(4) Removement of PHMC. 10-18 months after operation, PHMC can be removed by
choosing the primary incision, refrigerating PHMC, then prying the hooks of compressing
branch and semiring holding branch, and spreading the wings at last.

Figure 1.The delineation of PHMC and delineation of its plastic formation

Figure 2. Female,15 years old. a. The AP plate of shoulder joint 30 days after injury shows the
fracture of proximal humerus of Neer .b. The oboslete fracture of anatomical neck and
dislocation of caput humeralis.There is 3.7cm's displacement between ends of fractured bone.

Figure 3 . male,13 years old. a. The AP plate of sholder shows malunion of fracture of surgical
neck of humerus. enstrophe angle of caput humeralis is 100 b. The AP plate of sholder 6
months after operation fixed by PHMC ,rectified by osteotomy shows the anatomic
synostosis between caput humeralis and anatomical neck.

Figure 4. male,37 years old. a. The AP plate of sholder shows fracture of surgical neck of
humerus 11 months after ORIF by steel plate,100 's enstrophe angle of caput humeralis and
nonunion of fracture. b. The AP plate of sholder 5 months after the operation fixed by
PHMC shows anatomic synostosis.

Figure 5 . male,65 years old. a.The AP plate of sholder shows the fracture of greater tubercle
lesser tubercle and surgical neck,the compressed defection of medial anatomical neck and the
semiluxation of caput humeralis. b.c.d applying the circle temporarily made by steel wire
prevent bone pieces dispersing .e. The plate one and a half years after operation

<
Figure 6 .male,44 years old. a. The fracture of surgical neck associated with comminuted
fracture of proximal 1/4 of diaphysis. b. Applying arched toothed nail to fix the bone
pieces,finding foothold to apply bone graft and then whole fixing fracture by PHMC.c. The
plate of shoulder 5 months after operation shows synostosis.
Results :
Clinical result:
Common Information
Total 22 cases include comminuted fracture malunion and ununited fracture of proximal
humerus were treated by PHMC.There are 13 cases of fracture ,involving greater tubercle
lesser tubercle surgical neck and anatomic neck,4 cases of malunion and 5 cases of ununited
fracture among them. There were 15 males and 7 females. The age ranged from 13 to 69 years
(arerage 41.7 years);
Result
All cases were followed up from 6 to 37 monthes, average 18.5 months. The fracture attained
synostosis at an average time of 3.6 monthses ,and the ununited fracture was at 4.5 monthses.
All the fracture sites were replaced by lamellar bone,and there were no disordered bony
callus .External fixation was not needed after operation by PHMC.After trauma response
(about 7-12 days after operation), the patient should begin to functional exercise actively and
gradually. The average score of shoulder joint function is 88.5 according to the criteria of
Michael Reese [9]
Conclusion:
3D Biomechanic Characteristics of PHMC[10-13]
(1) The directing branch of head part and the semiring holding branch outside the articular
capsule and the axial compression part provide the mnemonic compressive stress that does not
disappear because of absorption of fracture line. It can provide dynamic stimulus for the

ossification.
(2) The stabilization of multiple points providing by difference between internal diameter of
PHMC and external diameter of bone belongs to the 3D stabilization of non- axis and non- side
wall.
(3) The patient can do functional exercise actively and gradually after trauma response (7-12
d). so the PHMC not
only can stabilize bone pieces, but also can accustom the straining of the muscle group on the
place .
The Indication of PHMC
The various fracture and nonunion of the region from anatomical neck to the diaphysis part of
the proximal humerus.
The Characteristic and Management of Above Region
On one hand, comminuted fracture of the region usually have different compressed cancellous
defect. On the other hand, cortical bone of the surgery neck is thin. So it is difficult to find
fixing location if crashed. There is more hollow yellow marrow on surgical neck of the old, so
it is difficult to get supporting locoation to reunion if crashed. These characteristics put forward
the problems how to apply bone graft. The tips for bone graft are as follows.
(1) Building up the fulcrum of defection. The iliac bone block is chiseled from the site 4cm
behinds anterior superior iliac spine, extending 2-3cm along iliac crest backwards, then
descending 4cm down. So the bone graft is about 4cm long and 2-3cm wide. The crest of iliac
bone graft is broadest position of iliac bone graft . The cancellated bone of it is exposed.The
large surface of iliac bone graft is taken to contact the cancellated bone of cancellated bone.
Another end of iliac bone graft is trimmed the same size of the medullary cavity and inserted
into the cavity.
(2) Filling up the space surrounding the defection The space between PHMC and bone is filled
with mixed scum of ilium and recombinated heterogeneic bone.
(3) Build up the exterior anatomic form of the defection. The bone stick spanned the defection
like splints, clamped by bone holding wing.
Above 3 points fits the case of nonunion,too. Comprehensive treatment is applied to the special
case showed by fig.5 and fig.6.
The Characteristic of Fixation and Ossification of PHMC
The 3D mnemonic dynamic mechanic environment of PHMC, the characteristic of bone graft

and the anatomic figure of proximal humerus effect each other.which creats multipolar 3D
force field. The difference of diameter between PHMC and bone and multipoint fixation
promote the recovery blood supply. The mnemonic compression between fracture site promotes
the ossification. All the fracture sites were replaced by lamellar bone,and there were no
disordered bony callus. This kind of healing appears accompanying with the active and gradual
functional exercise after trauma reaction.The unification of valid fixation, ossification, function
recovery is attained on the whole [10,11].
The Clinical Significance of PHMC
For the fracture of the region from anatomical neck to the surgical neck of the proximal
humerus,the prosthetic replacement is recommended more and more frequently. The reason is
as follows. At first,It is difficult to fix this kinds of fracture by plate and/or tension band; On the
orther hand, Kuner etc.[14] report the rate of ischemic necrosis of caput humeralis is 44.6% for
the fracture of proximal humerus fixed by plate, the rate is 33.3% for the fracture limited fixed
by
screw tension band and polydimethylsiloxane(PDS). The result of prosthetic replacement
caused by ischemic necrosis for the old is fair, but for the young, the problem caused by
replacement also allows of no optimism[15]. The result of study shows the PHMC can make
the fracture attain anatomic reduction and bone healing, There is no report of ischemic necrosis
so far. Certainly, we still needs the long-term observation on the big sample, but at least the
case showed by fig.4 is worth us more exploration and thought.
The Limitation of PHMC
The PHMC is not suitable for compressed comminuted fracture of the region from anatomical
neck to the caput humeralis. How to fix this kind of fracture effectively, reduce the prosthetic
replacement and recover the function as soon as possible is still a topic that needs to continue to
approach.
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