Postoperative radiographic evaluation of reduction loss in unstable proximal humerus fractures: A comparative study of intramedullary nails and locking plates in patients over 50 years

Postoperative radiographic evaluation of reduction loss in unstable proximal humerus fractures: A comparative study of intramedullary nails and locking plates in patients over 50 years | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Postoperative radiographic evaluation of reduction loss in unstable proximal humerus fractures: A comparative study of intramedullary nails and locking plates in patients over 50 years Guilherme Boni, Thomas Stravinskas Durigon, Robinson Pires, Henrique Paradella Alvachian Fernandes, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6421376/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Sep, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted 9 You are reading this latest preprint version Abstract Objective Evaluate radiographic outcomes of patients over 50 years old who underwent plate or nail fixation for proximal humeral fractures within 6 months of follow-up. Methods A retrospective observational study with 222 patients was conducted in a single tertiary hospital to evaluate radiographic outcomes of patients who underwent surgery for fracture fixation of unstable proximal humerus fractures. Inclusion criteria were patients over 50 years old who underwent fixation using intramedullary nails or locking plates (Neer 2-, 3-, and 4-parts), from January 2016 to December 2019. Results The most prevalent Neer pattern was 3 parts (39.6%), followed by 2 parts (37.4%). Incidence of some degree of reduction loss was 40.2% in the plate group, against 24.8% in the nail group, but not necessarily requiring surgery revision. The incidence of surgery revision was 16.4% (37 revisions), being 13(35%) in the nail group and 24(65%) in the plate group. Neck-shaft angle ranged from 141.3º to 133.3º in the nail group and from 138.4º to 127.9º in the plate group. Conclusion In this retrospective series of patients over 50 years with displaced unstable proximal humeral fractures, intramedullary nail fixation was superior to locking plate fixation in terms of preventing reduction loss for Neer 2- and 3- parts. Despite the high incidence of some degree of reduction loss, only 16,4% of patients presented failure of fixation, requiring revision surgery. Proximal humerus fractures Intramedullary nail Locking plate Reduction loss Figures Figure 1 Figure 2 Figure 3 Introduction Proximal humerus fractures represent 4–10% of all fractures and 7% of the upper extremity ones [1]. In the elderly population, proximal humerus fractures are among the three most frequent fracture patterns [2]. The peculiar anatomy of the shoulder with several muscle insertions that may cause fracture displacement besides poor bone quality that generally accompanies the geriatric population make this fracture pattern challenging. Although in the last decade the literature has shown favorable clinical outcomes of the non-operative treatment over surgical fixation in the elderly population, some fracture patterns in active patients may benefit from restoration of the original shoulder anatomy and require surgical treatment [3,4]. The standard treatment method for unstable proximal humerus fractures is open reduction and internal fixation using locking plates. Intramedullary nail and joint replacement, more recently the reverse shoulder arthroplasty, are also helpful treatment options already incorporated in the therapeutic arsenal of the proximal humerus fracture in the elderly [5]. Indeed, angular stability with several screw options increases construct stability. Also, the pre-contoured low-profile shape that perfectly fits the lateral surface of the proximal humerus were relevant improvements and represented a paradigm brake in the treatment of proximal humerus fractures, especially for 3- and 4-parts in patients with poor bone quality. However, risk of infection, wound dehiscence, neurologic palsy, osteonecrosis, and reduction loss remains alive even with the constant development of modern implants. Reduction loss occurs in 4.2–13.7% of cases and is associated with several factors, including age, poor bone quality, severe comminution, technical issues, and poor adherence to the treatment [6]. Correct understanding of the factors that influence the prognosis is crucial to diminish complications. Intramedullary nailing procedure presents some potential advantages in comparison to the plate fixation: minimally invasive soft tissues friendly approach and theoretically lower risk of neurologic palsy [7]. Literature is controversial regarding safety and efficacy of plate fixation compared to nail fixation for displaced proximal humerus fractures, particularly in patients older than 50 years [7]. We hypothesized that the nail construct offers lower incidence of reduction loss in geriatric displaced unstable fractures of the proximal humerus. Radiographic outcomes of patients who underwent plate or nail fixation were compared to verify the incidence of reduction loss in a 6-month follow- up. Methods A retrospective observational study was conducted in a single tertiary hospital to evaluate radiographic outcomes of patients who underwent surgery for fracture fixation of unstable proximal humerus fractures. Inclusion criteria were patients over 50 years old who underwent fixation with intramedullary nails or locking plates (Neer 2-, 3-, and 4-parts), from January 2016 to December 2019. All patients who underwent plate fixation were operated on under anterolateral approach, using the Bioscience-Atria SP Locking Plate System® (Jaú - SP, Brazil). All patients who underwent nail fixation were operated on using the short Bioscience-Orion SP Intramedullary Nail System® (Jaú - SP, Brazil). Non-inclusion criteria were patients with open fractures, pathological fractures, polytraumatized, neurovascular injuries, incomplete medical records, and patients who underwent nonoperative treatment, plate fixation using the deltopectoral approach, and shoulder arthroplasty. All surgical procedures were performed under beach-chair positioning and fluoroscopy, by the same surgical team. Collected data included: Neck-shaft angle (NSA), calculated in the immediate postoperative period and 6 months after surgery, fracture type according to the Neer classification system, patient age, gender, reported surgical time, and failure of fixation. Ethical approval was obtained from the Ethics Committee of the involved Institution (approval protocol: 28507919.0.0000.8114). Results In total, 222 patients were included (185 female patients, corresponding to 83.33%, and 37 male patients, representing 16.67%). The age ranged from 51 to 94 years, with 72.7 years on average. Plate fixation was performed in 117 (52.7%), while nail fixation was performed in 105 (47.3%) patients. Table 1 depicts the mean, median, and standard deviation of the quantitative variables that were assessed during the study. Table 1 Comparison of the age of the patients, the neck-shaft angle in the immediate postoperative period, as well as in the late postoperative period (6 months later), the difference between them, the surgery time performed in minutes, in their mean variables, median, standard deviation, minimum, maximum coefficient of variation (CV), and its confidence interval, IPO: immediate postoperative, LPO: late postoperative. Description Average Median Standard Deviation C.V Min Max I.C Age 72,7 72 9,3 13% 51 94 1,2 IPO (NSA) 139,8 140 8,9 6% 120 169 1,2 LPO (NSA) 130,5 131 12,1 9% 78 155 1,6 Diference IPO – LPO 9,6 6 9,4 98% 0 48 1,2 Surgery time (min.) 119.9 120 49,6 41% 10 350 6,5 There was a normality of distribution of the quantitative variables using the Kolmogorov-Smirnov test. Surgical time was 119min ± 06. We used the equality of two proportions test to characterize the distribution of the relative frequency (percentages) of qualitative variables, and the percentages were always calculated for the total valid responses for each variable (Table 2 ). Table 2 This table depicts the number of patients of each group, number of reduction losses, the gender difference, and the fracture’s classifications according to the Neer system. N % P-Value Implant Nail 105 47,3% Plate 117 52,7% 0,255 Reduction loss No 149 67,1% Yes 73 32,9% < 0,001 Gender Female 185 83,3% Male 37 16,7% < 0,001 Neer Classification 2 parts 83 37,4% 0,626 3 parts 88 39,6% Ref 4 parts 51 23,0% < 0,001 Regarding Neer classification, the most prevalent pattern was 3-parts (39.6%), followed by 2-parts (37.4%) ( p-value = 0.626). It was observed that Neer 2- and 3-parts presented the highest rate of reduction loss when using plate fixation. The highest discrepancy was observed in 2 parts patterns, where rates of reduction loss reached 4.5% for nail and 56, 4% for plate fixation ( p-value < 0.001) (Table 3 ). Table 3 This table describes the comparison of reduction loss between nail and plate groups, according to the Neer classification system. Nail Plate Total P-valeau N % N % N % 2 Parts No 42 95,5% 17 43,6% 59 71,1% < 0,001 Yes 2 4,5% 22 56,4% 24 28,9% 3 Parts No 32 74,4% 22 48,9% 54 61,4% 0,014 Yes 11 25,6% 23 51,1% 34 38,6% 4 Parts No 5 27,8% 31 93,9% 36 70,6% < 0,001 Yes 13 72,2% 2 6,1% 15 29,4% All No 79 75,2% 70 59,8% 149 67,1% 0,015 Yes 26 24,8% 47 40,2% 73 32,9% Anecdotally, for the 4-part fracture patterns there was an inversion. The highest loss rate was found in the nail group (72.2%), against 6.1% losses in the plate group ( p-value < 0.001). Considering the total sample, the incidence of reduction loss in the plate group was 40.2%, against 24.8% in the nail group ( p-value = 0.015). Despite high incidence of some degree of reduction loss, only 16,4% of patients required revision surgery. Of the 37 revisions, 13 (35%) were in the nail group, while 24 (65%) were on the plate group (Table 3 ). Table 4 compares the neck-shaft angle in the immediate and late postoperative periods (6 months later) between nails and plates in the different classifications of neer and in the total number of surgeries performed. Table 4 Comparison of immediate and late neck-shaft angle. IPO AVERAGE MEDIAN STANDARD DEVIATION CV MIN MAX N CI P – VALue Nail IPO 141,5 142 8,4 6% 127 160 44 2,5 < 0,001 2 Parts LPO 137,8 137 8,9 6% 120 154 44 2,6 < 0,001 Plate IPO 137,6 139 8,5 6% 120 161 39 2,7 < 0,001 LPO 123,5 126 12,9 10% 78 144 39 4,1 < 0,001 Nail IPO 140,0 139 8,6 6% 122 156 43 2,6 < 0,001 3 Parts LPO 132,4 131 12,5 9% 109 155 43 3,7 < 0,001 Plate IPO 139,1 139 10,6 8% 120 169 45 3,1 < 0,001 LPO 127,1 130 10,2 8% 97 144 45 3,0 < 0,001 Nail IPO 144,2 144,5 8,7 6% 133 167 18 4,0 < 0,001 4 Parts LPO 124,5 129,5 12,0 10% 100 141 18 5,5 < 0,001 Plate IPO 138,4 139 7,4 5% 122 150 33 2,5 < 0,001 LPO 134,1 135 9,4 7% 108 149 33 3,2 < 0,001 Nail IPO 141,3 141 8,6 6% 122 167 105 1,6 < 0,001 ALL LPO 133,3 133 11,9 9% 100 155 105 2,3 < 0,001 Plate IPO 138,4 139 9,1 7% 120 169 117 1,6 < 0,001 LPO 127,9 130 11,7 9% 78 149 117 2,1 < 0,001 Neck-shaft angle ranged from 141.3º to 133.3º ( p-value < 0.001) in the nail group, while in the plate group it ranged from 138.4º to 127.9º ( p-value < 0.001) (Table 4 ). Discussion Treatment of displaced unstable proximal humerus fractures in the elderly population remains controversial. Although recent studies highlighted comparable outcomes between non-operative and operative treatment, even for 3- and 4-part fracture patterns, the literature lacks clear evidence of the gold standard method [8]. More recently, the reverse shoulder arthroplasty gained visibility with promising functional outcomes [9]. However, the need of a long learning curve and the cost-related issues make this treatment option an alternative but not the routine procedure in current surgical practice. Locking plate fixation and intramedullary nailing are the most popular methods for fixation of displaced unstable proximal humeral fractures. Recent advances in proximal humeral nail systems, such as multiple multidirectional proximal locking screws and the straight shape, allowing for an articular entry point which prevents the supraspinatus tendon damage were relevant improvements and contributed to increase nail fixation in clinical practice. In our sample however, due to cost issues, we used a multidirectional short proximal nail but with lateral bend and entry point on the footprint area of the rotator cuff. Ming Li et al. [10] in a meta-analysis of 1384 patients comparing nails and plates for proximal humeral fractures reported that patients undergoing nail fixation evolved with lower bleeding and smaller incision but the with similar functional outcomes. Plath et al. [11] in a randomized clinical trial compared nail and plate fixation in elderly patients and concluded that there is no significant difference between both implants regarding pain, mobility, and functional outcome. Cocco et al. [12] assessed the life quality using the WORC Quality of Life Protocol in patients who underwent nail fixation of proximal humerus fractures and reported favorable outcomes. In this study, we hypothesized that nail fixation, due to its soft tissue friendly and mechanical properties, would lead to more favorable outcomes when compared to locking plates in the elderly population. The data analysis showed that nails obtained favorable results in comparison to plates in terms of preventing reduction loss for Neer 2- and 3-parts. Furthermore, surgical time of the procedure was shorter in the nail group, but no statistical significance was observed. In 4-parts Neer patterns, plates presented a lower rate of reduction loss. This finding must be interpreted with caution since only 2 patients with 4-parts fracture underwent plate fixation while 13 patients with 4-parts fracture underwent nail fixation. It is important to highlight that presenting some degree of reduction loss does not necessarily imply failure of fixation. The main criteria to diagnose loss of reduction was the neck-shaft angle (NSA), which was observed in the antero-posterior (AP) radiographic view of the shoulder. This angle is established by the intersection of 3 lines: one tangent to the articular surface, one perpendicular to the articular surface line, and the last one through the long axis of the humerus diaphysis. Bai et al. [13], in a prospective study analyzed 71 patients and used a difference of more than 10º to stablish varus collapse. Our study considered the difference of more than 15º in NSA to diagnose this collapse, since we observed that patients who presented more than 15º of varus collapse evolved with important limitations in range of motion and daily activities. We recognize limitations in the present study. The retrospective design is per se a potential limitation. Six-month follow-up may be insufficient to predict late fixation failure. The radiographic analysis is also a bias since humerus rotation may potentially change the neck-shaft angle and lead to inaccurate measurements. The findings depicting favorable results in terms of reduction loss when using nails do not necessarily represent a failure of fixation that requires surgery revision or replacement. Moreover, in the 4-parts Neer group the distribution of patients who underwent nail and plate fixation was not homogeneous. However, some strengths should be highlighted. Our sample size of 222 is representative and relevant when compared to previous studies, especially considering that we included only patients over 50 years old. We have included only patients who underwent anterolateral approach for plate fixation since it is the preferred approach of the involved surgeons and the inclusion of patients who underwent deltopectoral approach would be another potential bias. Conclusion In this retrospective observational study of patients over 50 years with displaced unstable proximal humeral fractures, intramedullary nail fixation was superior to locking plate fixation in terms of reduction loss for Neer 2- and 3- parts. Despite high incidence of some degree of reduction loss, only 16,4% of patients presented failure of fixation and require revision surgery. Declarations This paper doesn’t have any funding. Author Contribution We divided ourselves, and each one was responsible for a part of the paper, being the divisions: writing, data collection, statistics and submission. Acknowledgements Not applicable Competing Interests The authors of the study declare that they have no conflict of interest related to this manuscript. References Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone . 1996;18(3 Suppl):209S-213S. doi:10.1016/8756-3282(95)00504-8 Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology . 1996;7(6):612-18. doi:10.1097/00001648-199611000-00008 Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH, Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018 Aug;27(8):1526-1534. doi: 10.1016/j.jse.2018.03.009. Epub 2018 May 4. PMID: 29735376. Launonen AP, Sumrein BO, Reito A, Lepola V, Paloneva J, Jonsson KB, Wolf O, Ström P, Berg HE, Felländer-Tsai L, Jansson KÅ, Fell D, Mechlenburg I, Døssing K, Østergaard H, Märtson A, Laitinen MK, Mattila VM; as the NITEP group. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019 Jul 18;16(7): e1002855. doi: 10.1371/journal.pmed.1002855. PMID: 31318863; PMCID: PMC6638737. Schliemann B, Wähnert D, Theisen C, et al. How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. Injury . 2015;46(7):1207-14. doi:10.1016/j.injury.2015.04.020 Bahrs C, Kühle L, Blumenstock G, Stöckle U, Rolauffs B, Freude T. Which parameters affect medium- to long-term results after angular stable plate fixation for proximal humeral fractures?. J Shoulder Elbow Surg . 2015;24(5):727-32. doi:10.1016/j.jse.2014.08.009 Shi X, Liu H, Xing R, et al. Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. J Orthop Surg Res . 2019;14(1):285. Published 2019 Aug 30. doi:10.1186/s13018-019-1345-0 Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011 Jul;20(5):747-55. doi: 10.1016/j.jse.2010.12.018. Epub 2011 Mar 24. PMID: 21435907. Jonsson EÖ, Ekholm C, Salomonsson B, Demir Y, Olerud P; Collaborators in the SAPF Study Group. Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial. J Shoulder Elbow Surg. 2021 May;30(5):994-1006. doi: 10.1016/j.jse.2020.10.037. Epub 2020 Dec 7. PMID: 33301926. Li M, Wang Y, Zhang Y, Yang M, Zhang P, Jiang B. Intramedullary nail versus locking plate for treatment of proximal humeral fractures: A meta-analysis based on 1384 individuals. J Int Med Res. 2018 Nov;46(11):4363-4376. doi: 10.1177/0300060518781666. Epub 2018 Oct 1. PMID: 30270807; PMCID: PMC6259395. Plath JE, Kerschbaum C, hSeebauer T, et al. Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial. BMC Musculoskelet Disord . 2019;20(1):20. Published 2019 Jan 10. doi:10.1186/s12891-019-2399-1 Cocco LF, Ejnisman B, Belangero PS, Cohen M, Dos Reis FB. Quality of life after antegrade intramedullary nail fixation of humeral fractures: a survey in a selected cohort of Brazilian patients. Patient Saf Surg . 2018;12:4. Published 2018 Mar 12. doi:10.1186/s13037-018-0150- Bai L, Fu ZG, Wang TB, Chen JH, Zhang PX, Zhang DY, Jiang BG. Radiological evaluation of reduction loss in unstable proximal humeral fractures treated with locking plates. Orthop Traumatol Surg Res. 2014 May;100(3):271-4. doi: 10.1016/j.otsr.2013.12.024. Epub 2014 Apr 4. PMID: 24709305. Additional Declarations No competing interests reported. Supplementary Files HighlightsV2.docx Cite Share Download PDF Status: Published Journal Publication published 25 Sep, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted Editorial decision: Revision requested 14 Jul, 2025 Reviews received at journal 21 Jun, 2025 Reviewers agreed at journal 15 Jun, 2025 Reviewers agreed at journal 12 Jun, 2025 Reviewers agreed at journal 03 May, 2025 Reviewers invited by journal 29 Apr, 2025 Editor assigned by journal 25 Apr, 2025 Submission checks completed at journal 23 Apr, 2025 First submitted to journal 10 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6421376","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":451749458,"identity":"e390ed52-9b2a-4704-9091-6fea9d165301","order_by":0,"name":"Guilherme Boni","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYFACxgYGBjYbOQYGHpgIDx7VCC1pxqRoAQG2w4kNRGuRj0hu3fCh7HD6huNnDz74wGAnp9vAe+wDPi2GNxLbbs44l5674UxesuEMhmRjswN8yTPwapmR2Habt806d8OBHDNpHoYDidsO8BjjdRhYy9825nSD82+I1CIvAdTC2OacYHCDWFsMeB623ew5l2Y488YbY8MZBkC/HOZLxm9Le/qzGz/KbOT5zucYPvhQYSdndrz3MH5bDkAZCmCGARAz49UAtKUBnTEKRsEoGAWjAB0AAB2hTU2P4H7JAAAAAElFTkSuQmCC","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Guilherme","middleName":"","lastName":"Boni","suffix":""},{"id":451749459,"identity":"8091d5f8-3d24-45c8-b5a0-6a76b268fd80","order_by":1,"name":"Thomas Stravinskas Durigon","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Stravinskas","lastName":"Durigon","suffix":""},{"id":451749460,"identity":"76602a25-f0c7-478e-9099-cd8bf87b9e4a","order_by":2,"name":"Robinson Pires","email":"","orcid":"","institution":"Universidade Federal de Minas Gerais","correspondingAuthor":false,"prefix":"","firstName":"Robinson","middleName":"","lastName":"Pires","suffix":""},{"id":451749461,"identity":"d1677619-c811-488d-89b4-659609e4fdfc","order_by":3,"name":"Henrique Paradella Alvachian Fernandes","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Henrique","middleName":"Paradella Alvachian","lastName":"Fernandes","suffix":""},{"id":451749462,"identity":"036b8851-cfeb-40be-9a6b-b6f0e35e3d20","order_by":4,"name":"Gustavo Tadeu Sanchez","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Gustavo","middleName":"Tadeu","lastName":"Sanchez","suffix":""},{"id":451749463,"identity":"d26a3fb9-4a69-4990-afe8-137249748143","order_by":5,"name":"Thomas Pesce Cavanha Gaia","email":"","orcid":"","institution":"Federal University of São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Pesce Cavanha","lastName":"Gaia","suffix":""}],"badges":[],"createdAt":"2025-04-10 15:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6421376/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6421376/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00590-025-04497-w","type":"published","date":"2025-09-25T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82278729,"identity":"1e49b1a8-cbd4-4f99-bd63-9ddb2b1315c3","added_by":"auto","created_at":"2025-05-08 14:57:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21652,"visible":true,"origin":"","legend":"\u003cp\u003eFigure 1. Flowchart depicting the inclusion and non-inclusion criteria of the sample.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6421376/v1/38e5431a4d9378f958d8325d.png"},{"id":82278732,"identity":"c2b29918-4990-4ddf-8351-d36e3090ff3f","added_by":"auto","created_at":"2025-05-08 14:57:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36796,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e: Radiographs A-F depict a patient with proximal humerus fracture (4-parts according to the Neer classification), who underwent nail fixation and evolved withreduction loss. Figures A and B show the 4-part fracture and C and D the fixation with an intramedullary nail. E and F radiographs show the reduction loss and varus colapse after 23 days post-surgery.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6421376/v1/8c5de6eaf459d802dff1a4ce.jpg"},{"id":82279545,"identity":"50d01e55-b100-4b18-875a-1d6fdbdc33bc","added_by":"auto","created_at":"2025-05-08 15:05:19","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28414,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2:\u003c/strong\u003eFigure 2 depicts a patient with proximal humerus 4-parts fracture pattern treated with a locking plate. The patient evolved with loss of reduction after 17 days post-surgery. Fluoroscopy images A and B show the postoperative anteroposteriorand lateral views of the left shoulder, with the restoration of the NSA. Seventeen days postoperatively, one can observe fracture impaction with screws penetration into the humeral head, characterizing reduction loss (C and D).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6421376/v1/1184674e24cc2c7ead7a7a5f.jpg"},{"id":92430612,"identity":"7735058c-e63e-471e-88cc-de16a17e365b","added_by":"auto","created_at":"2025-09-29 16:06:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":766940,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6421376/v1/4e079b8e-ac2d-4b27-9ab0-94a4a037d9b2.pdf"},{"id":82278736,"identity":"abde9e35-5867-448f-8e8c-4494faf9d997","added_by":"auto","created_at":"2025-05-08 14:57:19","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":14303,"visible":true,"origin":"","legend":"","description":"","filename":"HighlightsV2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6421376/v1/05ea7aaa0b5943f8b991c30f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Postoperative radiographic evaluation of reduction loss in unstable proximal humerus fractures: A comparative study of intramedullary nails and locking plates in patients over 50 years","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProximal humerus fractures represent 4\u0026ndash;10% of all fractures and 7% of the upper extremity ones [1]. In the elderly population, proximal humerus fractures are among the three most frequent fracture patterns [2]. The peculiar anatomy of the shoulder with several muscle insertions that may cause fracture displacement besides poor bone quality that generally accompanies the geriatric population make this fracture pattern challenging.\u003c/p\u003e \u003cp\u003eAlthough in the last decade the literature has shown favorable clinical outcomes of the non-operative treatment over surgical fixation in the elderly population, some fracture patterns in active patients may benefit from restoration of the original shoulder anatomy and require surgical treatment [3,4].\u003c/p\u003e \u003cp\u003eThe standard treatment method for unstable proximal humerus fractures is open reduction and internal fixation using locking plates. Intramedullary nail and joint replacement, more recently the reverse shoulder arthroplasty, are also helpful treatment options already incorporated in the therapeutic arsenal of the proximal humerus fracture in the elderly [5].\u003c/p\u003e \u003cp\u003eIndeed, angular stability with several screw options increases construct stability. Also, the pre-contoured low-profile shape that perfectly fits the lateral surface of the proximal humerus were relevant improvements and represented a paradigm brake in the treatment of proximal humerus fractures, especially for 3- and 4-parts in patients with poor bone quality. However, risk of infection, wound dehiscence, neurologic palsy, osteonecrosis, and reduction loss remains alive even with the constant development of modern implants. Reduction loss occurs in 4.2\u0026ndash;13.7% of cases and is associated with several factors, including age, poor bone quality, severe comminution, technical issues, and poor adherence to the treatment [6]. Correct understanding of the factors that influence the prognosis is crucial to diminish complications.\u003c/p\u003e \u003cp\u003eIntramedullary nailing procedure presents some potential advantages in comparison to the plate fixation: minimally invasive soft tissues friendly approach and theoretically lower risk of neurologic palsy [7].\u003c/p\u003e \u003cp\u003eLiterature is controversial regarding safety and efficacy of plate fixation compared to nail fixation for displaced proximal humerus fractures, particularly in patients older than 50 years [7].\u003c/p\u003e \u003cp\u003eWe hypothesized that the nail construct offers lower incidence of reduction loss in geriatric displaced unstable fractures of the proximal humerus. Radiographic outcomes of patients who underwent plate or nail fixation were compared to verify the incidence of reduction loss in a 6-month follow- up.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective observational study was conducted in a single tertiary hospital to evaluate radiographic outcomes of patients who underwent surgery for fracture fixation of unstable proximal humerus fractures. Inclusion criteria were patients over 50 years old who underwent fixation with intramedullary nails or locking plates (Neer 2-, 3-, and 4-parts), from January 2016 to December 2019. All patients who underwent plate fixation were operated on under anterolateral approach, using the Bioscience-Atria SP Locking Plate System\u0026reg; (Ja\u0026uacute; - SP, Brazil). All patients who underwent nail fixation were operated on using the short Bioscience-Orion SP Intramedullary Nail System\u0026reg; (Ja\u0026uacute; - SP, Brazil). Non-inclusion criteria were patients with open fractures, pathological fractures, polytraumatized, neurovascular injuries, incomplete medical records, and patients who underwent nonoperative treatment, plate fixation using the deltopectoral approach, and shoulder arthroplasty.\u003c/p\u003e\u003cp\u003eAll surgical procedures were performed under beach-chair positioning and fluoroscopy, by the same surgical team.\u003c/p\u003e \u003cp\u003eCollected data included: Neck-shaft angle (NSA), calculated in the immediate postoperative period and 6 months after surgery, fracture type according to the Neer classification system, patient age, gender, reported surgical time, and failure of fixation.\u003c/p\u003e \u003cp\u003eEthical approval was obtained from the Ethics Committee of the involved Institution (approval protocol: 28507919.0.0000.8114).\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 222 patients were included (185 female patients, corresponding to 83.33%, and 37 male patients, representing 16.67%). The age ranged from 51 to 94 years, with 72.7 years on average. Plate fixation was performed in 117 (52.7%), while nail fixation was performed in 105 (47.3%) patients.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the mean, median, and standard deviation of the quantitative variables that were assessed during the study.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the age of the patients, the neck-shaft angle in the immediate postoperative period, as well as in the late postoperative period (6 months later), the difference between them, the surgery time performed in minutes, in their mean variables, median, standard deviation, minimum, maximum coefficient of variation (CV), and its confidence interval, IPO: immediate postoperative, LPO: late postoperative.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC.V\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eI.C\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPO (NSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLPO (NSA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiference IPO \u0026ndash; LPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1,2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (min.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThere was a normality of distribution of the quantitative variables using the Kolmogorov-Smirnov test. Surgical time was 119min\u0026thinsp;\u0026plusmn;\u0026thinsp;06.\u003c/p\u003e \u003cp\u003eWe used the equality of two proportions test to characterize the distribution of the relative frequency (percentages) of qualitative variables, and the percentages were always calculated for the total valid responses for each variable (Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThis table depicts the number of patients of each group, number of reduction losses, the gender difference, and the fracture\u0026rsquo;s classifications according to the Neer system.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47,3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52,7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduction loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67,1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32,9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83,3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16,7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeer Classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37,4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,626\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39,6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23,0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding Neer classification, the most prevalent pattern was 3-parts (39.6%), followed by 2-parts (37.4%) (\u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.626).\u003c/p\u003e \u003cp\u003eIt was observed that Neer 2- and 3-parts presented the highest rate of reduction loss when using plate fixation. The highest discrepancy was observed in 2 parts patterns, where rates of reduction loss reached 4.5% for nail and 56, 4% for plate fixation (\u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThis table describes the comparison of reduction loss between nail and plate groups, according to the Neer classification system.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNail\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePlate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP-valeau\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 Parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95,5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43,6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e71,1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56,4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e28,9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74,4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48,9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e61,4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25,6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51,1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e38,6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 Parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27,8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93,9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e70,6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72,2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6,1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e29,4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75,2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59,8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e67,1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0,015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24,8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40,2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32,9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAnecdotally, for the 4-part fracture patterns there was an inversion. The highest loss rate was found in the nail group (72.2%), against 6.1% losses in the plate group (\u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Considering the total sample, the incidence of reduction loss in the plate group was 40.2%, against 24.8% in the nail group (\u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015).\u003c/p\u003e \u003cp\u003eDespite high incidence of some degree of reduction loss, only 16,4% of patients required revision surgery. Of the 37 revisions, 13 (35%) were in the nail group, while 24 (65%) were on the plate group (Table\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares the neck-shaft angle in the immediate and late postoperative periods (6 months later) between nails and plates in the different classifications of neer and in the total number of surgeries performed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of immediate and late neck-shaft angle.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAVERAGE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMEDIAN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSTANDARD\u003c/p\u003e \u003cp\u003eDEVIATION\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMIN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMAX\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eP \u0026ndash; VALue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e141,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 Parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e137,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e137,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e123,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e140,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e132,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e139,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e127,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e144,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e144,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 Parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e124,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e129,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e138,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e134,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e141,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e133,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e138,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLPO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e127,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNeck-shaft angle ranged from 141.3\u0026ordm; to 133.3\u0026ordm; (\u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the nail group, while in the plate group it ranged from 138.4\u0026ordm; to 127.9\u0026ordm; (\u003cem\u003ep-value\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTreatment of displaced unstable proximal humerus fractures in the elderly population remains controversial. Although recent studies highlighted comparable outcomes between non-operative and operative treatment, even for 3- and 4-part fracture patterns, the literature lacks clear evidence of the gold standard method [8]. More recently, the reverse shoulder arthroplasty gained visibility with promising functional outcomes [9]. However, the need of a long learning curve and the cost-related issues make this treatment option an alternative but not the routine procedure in current surgical practice. Locking plate fixation and intramedullary nailing are the most popular methods for fixation of displaced unstable proximal humeral fractures. Recent advances in proximal humeral nail systems, such as multiple multidirectional proximal locking screws and the straight shape, allowing for an articular entry point which prevents the supraspinatus tendon damage were relevant improvements and contributed to increase nail fixation in clinical practice. In our sample however, due to cost issues, we used a multidirectional short proximal nail but with lateral bend and entry point on the footprint area of the rotator cuff.\u003c/p\u003e \u003cp\u003eMing Li et al. [10] in a meta-analysis of 1384 patients comparing nails and plates for proximal humeral fractures reported that patients undergoing nail fixation evolved with lower bleeding and smaller incision but the with similar functional outcomes.\u003c/p\u003e \u003cp\u003ePlath et al. [11] in a randomized clinical trial compared nail and plate fixation in elderly patients and concluded that there is no significant difference between both implants regarding pain, mobility, and functional outcome.\u003c/p\u003e \u003cp\u003eCocco et al. [12] assessed the life quality using the WORC Quality of Life Protocol in patients who underwent nail fixation of proximal humerus fractures and reported favorable outcomes.\u003c/p\u003e \u003cp\u003eIn this study, we hypothesized that nail fixation, due to its soft tissue friendly and mechanical properties, would lead to more favorable outcomes when compared to locking plates in the elderly population.\u003c/p\u003e \u003cp\u003eThe data analysis showed that nails obtained favorable results in comparison to plates in terms of preventing reduction loss for Neer 2- and 3-parts. Furthermore, surgical time of the procedure was shorter in the nail group, but no statistical significance was observed. In 4-parts Neer patterns, plates presented a lower rate of reduction loss. This finding must be interpreted with caution since only 2 patients with 4-parts fracture underwent plate fixation while 13 patients with 4-parts fracture underwent nail fixation.\u003c/p\u003e \u003cp\u003eIt is important to highlight that presenting some degree of reduction loss does not necessarily imply failure of fixation. The main criteria to diagnose loss of reduction was the neck-shaft angle (NSA), which was observed in the antero-posterior (AP) radiographic view of the shoulder. This angle is established by the intersection of 3 lines: one tangent to the articular surface, one perpendicular to the articular surface line, and the last one through the long axis of the humerus diaphysis.\u003c/p\u003e \u003cp\u003eBai et al. [13], in a prospective study analyzed 71 patients and used a difference of more than 10\u0026ordm; to stablish varus collapse. Our study considered the difference of more than 15\u0026ordm; in NSA to diagnose this collapse, since we observed that patients who presented more than 15\u0026ordm; of varus collapse evolved with important limitations in range of motion and daily activities.\u003c/p\u003e \u003cp\u003eWe recognize limitations in the present study. The retrospective design is per se a potential limitation. Six-month follow-up may be insufficient to predict late fixation failure. The radiographic analysis is also a bias since humerus rotation may potentially change the neck-shaft angle and lead to inaccurate measurements. The findings depicting favorable results in terms of reduction loss when using nails do not necessarily represent a failure of fixation that requires surgery revision or replacement. Moreover, in the 4-parts Neer group the distribution of patients who underwent nail and plate fixation was not homogeneous. However, some strengths should be highlighted. Our sample size of 222 is representative and relevant when compared to previous studies, especially considering that we included only patients over 50 years old. We have included only patients who underwent anterolateral approach for plate fixation since it is the preferred approach of the involved surgeons and the inclusion of patients who underwent deltopectoral approach would be another potential bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this retrospective observational study of patients over 50 years with displaced unstable proximal humeral fractures, intramedullary nail fixation was superior to locking plate fixation in terms of reduction loss for Neer 2- and 3- parts. Despite high incidence of some degree of reduction loss, only 16,4% of patients presented failure of fixation and require revision surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis paper doesn\u0026rsquo;t have any funding.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWe divided ourselves, and each one was responsible for a part of the paper, being the divisions: writing, data collection, statistics and submission.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eCompeting Interests\u003c/h2\u003e\n\u003cp\u003eThe authors of the study declare that they have no conflict of interest related to this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. \u003cem\u003eBone\u003c/em\u003e. 1996;18(3 Suppl):209S-213S. doi:10.1016/8756-3282(95)00504-8\u003c/li\u003e\n\u003cli\u003eBaron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. \u003cem\u003eEpidemiology\u003c/em\u003e. 1996;7(6):612-18. doi:10.1097/00001648-199611000-00008\u003c/li\u003e\n\u003cli\u003eBeks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH, Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018 Aug;27(8):1526-1534. doi: 10.1016/j.jse.2018.03.009. Epub 2018 May 4. PMID: 29735376.\u003c/li\u003e\n\u003cli\u003eLaunonen AP, Sumrein BO, Reito A, Lepola V, Paloneva J, Jonsson KB, Wolf O, Str\u0026ouml;m P, Berg HE, Fell\u0026auml;nder-Tsai L, Jansson K\u0026Aring;, Fell D, Mechlenburg I, D\u0026oslash;ssing K, \u0026Oslash;stergaard H, M\u0026auml;rtson A, Laitinen MK, Mattila VM; as the NITEP group. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019 Jul 18;16(7): e1002855. doi: 10.1371/journal.pmed.1002855. PMID: 31318863; PMCID: PMC6638737.\u003c/li\u003e\n\u003cli\u003eSchliemann B, W\u0026auml;hnert D, Theisen C, et al. How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. \u003cem\u003eInjury\u003c/em\u003e. 2015;46(7):1207-14. doi:10.1016/j.injury.2015.04.020\u003c/li\u003e\n\u003cli\u003eBahrs C, K\u0026uuml;hle L, Blumenstock G, St\u0026ouml;ckle U, Rolauffs B, Freude T. Which parameters affect medium- to long-term results after angular stable plate fixation for proximal humeral fractures?. \u003cem\u003eJ Shoulder Elbow Surg\u003c/em\u003e. 2015;24(5):727-32. doi:10.1016/j.jse.2014.08.009\u003c/li\u003e\n\u003cli\u003eShi X, Liu H, Xing R, et al. Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. \u003cem\u003eJ Orthop Surg Res\u003c/em\u003e. 2019;14(1):285. Published 2019 Aug 30. doi:10.1186/s13018-019-1345-0\u003c/li\u003e\n\u003cli\u003eOlerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011 Jul;20(5):747-55. doi: 10.1016/j.jse.2010.12.018. Epub 2011 Mar 24. PMID: 21435907.\u003c/li\u003e\n\u003cli\u003eJonsson E\u0026Ouml;, Ekholm C, Salomonsson B, Demir Y, Olerud P; Collaborators in the SAPF Study Group. Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial. J Shoulder Elbow Surg. 2021 May;30(5):994-1006. doi: 10.1016/j.jse.2020.10.037. Epub 2020 Dec 7. PMID: 33301926.\u003c/li\u003e\n\u003cli\u003eLi M, Wang Y, Zhang Y, Yang M, Zhang P, Jiang B. Intramedullary nail versus locking plate for treatment of proximal humeral fractures: A meta-analysis based on 1384 individuals. J Int Med Res. 2018 Nov;46(11):4363-4376. doi: 10.1177/0300060518781666. Epub 2018 Oct 1. PMID: 30270807; PMCID: PMC6259395.\u003c/li\u003e\n\u003cli\u003ePlath JE, Kerschbaum C, hSeebauer T, et al. Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial. \u003cem\u003eBMC Musculoskelet Disord\u003c/em\u003e. 2019;20(1):20. Published 2019 Jan 10. doi:10.1186/s12891-019-2399-1\u003c/li\u003e\n\u003cli\u003eCocco LF, Ejnisman B, Belangero PS, Cohen M, Dos Reis FB. Quality of life after antegrade intramedullary nail fixation of humeral fractures: a survey in a selected cohort of Brazilian patients. \u003cem\u003ePatient Saf Surg\u003c/em\u003e. 2018;12:4. Published 2018 Mar 12. doi:10.1186/s13037-018-0150-\u003c/li\u003e\n\u003cli\u003eBai L, Fu ZG, Wang TB, Chen JH, Zhang PX, Zhang DY, Jiang BG. Radiological evaluation of reduction loss in unstable proximal humeral fractures treated with locking plates. Orthop Traumatol Surg Res. 2014 May;100(3):271-4. doi: 10.1016/j.otsr.2013.12.024. Epub 2014 Apr 4. PMID: 24709305.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Proximal humerus fractures, Intramedullary nail, Locking plate, Reduction loss","lastPublishedDoi":"10.21203/rs.3.rs-6421376/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6421376/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eEvaluate radiographic outcomes of patients over 50 years old who underwent plate or nail fixation for proximal humeral fractures within 6 months of follow-up.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective observational study with 222 patients was conducted in a single tertiary hospital to evaluate radiographic outcomes of patients who underwent surgery for fracture fixation of unstable proximal humerus fractures. Inclusion criteria were patients over 50 years old who underwent fixation using intramedullary nails or locking plates (Neer 2-, 3-, and 4-parts), from January 2016 to December 2019.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe most prevalent Neer pattern was 3 parts (39.6%), followed by 2 parts (37.4%). Incidence of some degree of reduction loss was 40.2% in the plate group, against 24.8% in the nail group, but not necessarily requiring surgery revision. The incidence of surgery revision was 16.4% (37 revisions), being 13(35%) in the nail group and 24(65%) in the plate group. Neck-shaft angle ranged from 141.3\u0026ordm; to 133.3\u0026ordm; in the nail group and from 138.4\u0026ordm; to 127.9\u0026ordm; in the plate group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn this retrospective series of patients over 50 years with displaced unstable proximal humeral fractures, intramedullary nail fixation was superior to locking plate fixation in terms of preventing reduction loss for Neer 2- and 3- parts. Despite the high incidence of some degree of reduction loss, only 16,4% of patients presented failure of fixation, requiring revision surgery.\u003c/p\u003e","manuscriptTitle":"Postoperative radiographic evaluation of reduction loss in unstable proximal humerus fractures: A comparative study of intramedullary nails and locking plates in patients over 50 years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 14:57:14","doi":"10.21203/rs.3.rs-6421376/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-14T06:52:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-22T03:33:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286725064008144917162949499943072047562","date":"2025-06-15T16:37:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118590944592902510175006514785276329058","date":"2025-06-12T12:21:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118590944592902510175006514785276329058","date":"2025-05-03T08:21:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-29T12:22:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-25T20:23:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-23T04:20:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Orthopaedic Surgery \u0026 Traumatology","date":"2025-04-10T14:53:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejos","sideBox":"Learn more about [European Journal of Orthopaedic Surgery \u0026 Traumatology](http://link.springer.com/journal/590)","snPcode":"590","submissionUrl":"https://submission.springernature.com/new-submission/590/3","title":"European Journal of Orthopaedic Surgery \u0026 Traumatology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2e4962e5-f803-445e-ab4b-582c2db70020","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T16:03:00+00:00","versionOfRecord":{"articleIdentity":"rs-6421376","link":"https://doi.org/10.1007/s00590-025-04497-w","journal":{"identity":"european-journal-of-orthopaedic-surgery-and-traumatology","isVorOnly":false,"title":"European Journal of Orthopaedic Surgery \u0026 Traumatology"},"publishedOn":"2025-09-25 15:57:30","publishedOnDateReadable":"September 25th, 2025"},"versionCreatedAt":"2025-05-08 14:57:14","video":"","vorDoi":"10.1007/s00590-025-04497-w","vorDoiUrl":"https://doi.org/10.1007/s00590-025-04497-w","workflowStages":[]},"version":"v1","identity":"rs-6421376","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6421376","identity":"rs-6421376","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}