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The Hertel classification can't predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach
Márcio Alves Cruz, Guilherme Grisi Mouraria
Corresponding author
mouraria@unicamp.br

Corresponding author.
, Fernando Kenji Kikuta, Daniel Romano Zogbi, Sérgio de Paula Coelho, Maurício Etchebehere
Orthopedics and Traumatology, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Radiographs showing initial fracture &#40;a&#41;&#59; one day after the surgery &#40;b&#41;&#59; six months after the surgery with radiological evidence of HHO &#40;c&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Introduction</span><p id="para0011" class="elsevierStylePara elsevierViewall">Proximal humeral fractures can progress to Humeral Head Osteonecrosis &#40;HHO&#41; as a result of blood supply interruption caused by trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> The anterior humeral circumflex artery is often damaged by trauma&#44; so the posterior humeral circumflex artery is of great importance in maintaining vascularization of the humeral head&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Fracture characteristics including comminution&#44; involvement of the articular surfaces&#44; and bone fragments in the posteromedial humerus&#44; may increase the risk of HHO&#46; Because of that&#44; the rates of osteonecrosis can range from&#160;0&#37;&#160;to&#160;75&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0003"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="para0012" class="elsevierStylePara elsevierViewall">The risk of HHO is an important factor in surgical decision-making&#46; Fractures with a high risk of necrosis &#40;especially in the elderly&#41; can be treated with arthroplasty&#46; In contrast&#44; young patients and&#47;or low-risk fractures may be treated with osteosynthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> Several authors have investigated fracture patterns and correlated them with the risk of HHO&#46; In&#160;1971&#44; Neer observed that four-part fractures were associated with a greater risk of necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> More recently&#44; Hertel developed a binary classification system &#40;12&#160;subtypes&#41; and demonstrated that patterns&#160;2&#44; 9&#44; 10&#44; 11&#44; and&#160;12&#44; and fractures with posteromedial head extension less than or equal to&#160;8&#160;mm&#44; or diaphysis deviation greater than&#160;2&#160;mm &#40;injury to the medial hinge&#41;&#44; were at increased risk for HHO&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a></p><p id="para0013" class="elsevierStylePara elsevierViewall">It remains controversial whether the Hertel classification can predict HHO risk&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> In Hertel&#39;s study&#44; humeral head perfusion was assessed intraoperatively through the deltopectoral approach&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a></p><p id="para0014" class="elsevierStylePara elsevierViewall">The period of time that the Proximal Humeral Head progress to osteonecrosis ranges from&#160;6&#160;months to&#160;2&#160;years and the diagnoses can be made using Radiographs&#46; The use of Magnetic Resonance can identify osteonecrosis in the early stage&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a></p><p id="para0015" class="elsevierStylePara elsevierViewall">Osteosynthesis for proximal humerus fractures can be performed using either a Deltopectoral or Anterolateral approach&#46; Both require muscle dissection and retraction for adequate lateral humerus exposure&#46; The anterolateral approach favors reaching the lateral aspect of the humerus because it&#39;s not necessary to retract the Deltoid and Pectoral Major Muscles&#46; Despite the fact that in anterolateral surgeons must dissect the axillar nerve&#44; the incidence of nerve injury is relatively rare&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0016" class="elsevierStylePara elsevierViewall">Hertel described the incidence and the risk factors after osteosynthesis using a Deltopectoral approach&#46; Few studies have evaluated the prevalence and the capacity of Hertl&#39;s classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a></p><p id="para0017" class="elsevierStylePara elsevierViewall">The Hypothesis is that Hertel&#39;s classification can predict the Risk of HHO after Osteosynthesis using Anterolateral Approach&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Objectives</span><p id="para0018" class="elsevierStylePara elsevierViewall">The primary objective of the study was to correlate osteonecrosis predictors&#44; established by the Hertel classification&#44; with the presence or absence of HHO following osteosynthesis of the proximal humerus through the anterolateral approach&#46;</p><p id="para0019" class="elsevierStylePara elsevierViewall">The secondary objective was to assess the prevalence of HHO after at least&#160;1&#160;year of postoperative follow-up&#46;</p></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Materials and methods</span><p id="para0020" class="elsevierStylePara elsevierViewall">This was a retrospective study of patients who underwent osteosynthesis for proximal humerus fractures via the anterolateral approach between&#160;2016 and&#160;2019&#46;</p><p id="para0021" class="elsevierStylePara elsevierViewall">Inclusion criteria&#58; Patients underwent fracture osteosynthesis using the anterolateral approach and had all the radiological images required for preoperative Hertel classification and for HHO evaluation&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">Exclusion criteria&#58; Cases without complete documentation&#44; fractures associated with a dislocation&#44; and pathological fractures&#46;</p><p id="para0023" class="elsevierStylePara elsevierViewall">Patients which suffered fractures as a result of falls from weight as considered was considered low trauma energy&#46; Motorcycles&#44; bicycles&#44; and accidents were considered high trauma energy&#46;</p><p id="para0024" class="elsevierStylePara elsevierViewall">The Hertel classification was used to classify fractures and stratify the risk of osteonecrosis&#46; Radiographs were taken in anteroposterior&#44; scapular&#44; and axillary views&#46; Preoperative investigations were evaluated by two examiners and the kappa test was used to assess agreement between examiners&#46; The Hertel classification was used to divide the patients into two groups&#46; Binary patterns&#160;2&#44; 9&#44; 10&#44; 11&#44; and&#160;12&#44; or posteromedial head extension less than or equal to&#160;8&#160;mm&#44; or diaphysis deviation greater than&#160;2&#160;mm &#40;injury to the medial hinge&#41;&#44; were allocated to group&#160;1 &#40;high risk for osteonecrosis&#41;&#46; Fractures with binary patterns&#160;1&#44; 3&#44; 4&#44; 5&#44; 6&#44; 7&#44; and&#160;8&#44; and&#47;or posteromedial head extension greater than&#160;8&#160;mm&#44; or diaphysis deviation less than&#160;2&#160;mm &#40;medial hinge integrity&#41; were allocated to group&#160;2 &#40;low-risk for necrosis&#41;&#46;</p><p id="para0025" class="elsevierStylePara elsevierViewall">Radiographic evaluations were performed using the SinapseR digital radiography program&#46; Postoperative radiological examinations were performed at least&#160;1&#160;year after the surgical procedure&#46; Osteonecrosis was identified by a radiologist&#46; The presence of a cist&#44; sclerotic changes in the Humeral Head&#44; and subcondral collapse producing a crescent sign in Radiographs were considered positive for osteonecrosis&#46;</p><p id="para0026" class="elsevierStylePara elsevierViewall">Patients underwent surgery in a beach chair position&#46; A&#160;10-cm incision was made from the anterolateral edge of the acromion in a distal direction and parallel to the axis of the diaphysis&#46; The anterior and middle portions of the deltoid were separated by blunt dissection and the axillary nerve was identified&#46; After fracture reduction and fixation&#44; a provisional plate with Kirschner wires &#40;Humerus Gm-Reis<span class="elsevierStyleSup">R</span>&#41; was placed on the lateral face of the humerus below the anterior branch of the axillary nerve&#46;</p><p id="para0027" class="elsevierStylePara elsevierViewall">The total prevalence of HHO and the prevalence in each group were calculated&#46; Comparisons between groups were performed using the Chi-Square or Fisher&#39;s exact tests&#46; Non-categorical variables were tested for normality using the Kolmogorov-Smirnov test&#46; The unpaired <span class="elsevierStyleItalic">t</span>-test &#40;parametric variables&#41; and the Mann-Whitney test &#40;non-parametric&#41; were also used&#46; A Kaplan-Meier curve was used to assess the pattern of the temporal evolution of osteonecrosis&#46; All analyzes were performed using the PASW statistics&#160;27&#46;0&#160;software &#40;IBM Corp&#46;&#44; Armonk&#44; NY&#44; USA&#41; adopting a significance level of&#160;5&#37;&#46;</p><p id="para0028" class="elsevierStylePara elsevierViewall">The research protocol was approved by the local ethics committee &#40;Campinas State University ethics committee &#8211; registration n&#176;&#160;34384120&#46;5&#46;0000&#46;540&#41;&#46; All methods were analyzed by this committee and were carried out in accordance with relevant guidelines and regulations&#46; Informed consent was obtained from all patients&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Results</span><p id="para0029" class="elsevierStylePara elsevierViewall">In total&#44; 39&#160;patients met the inclusion criteria&#44; with a predominance of females &#40;55&#46;3&#37;&#41;&#46; The average age was&#160;58&#46;4 &#177; 12&#46;0&#160;years&#46; The youngest patient was&#160;21 and the older was&#160;78&#160;years old&#46;</p><p id="para0030" class="elsevierStylePara elsevierViewall">Patients who underwent surgery ranged from&#160;1&#160;to&#160;15&#160;days after the trauma&#46; Postoperative follow-up time was&#160;14&#46;5 &#177; 3&#46;3&#160;months&#46; <a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a> lists demographic data&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia><p id="para0031" class="elsevierStylePara elsevierViewall">In terms of an agreement between observers&#44; the lowest level was reached for the fracture extension criterion for the medial region of the head smaller than&#160;8&#160;mm &#40;Kappa&#160;&#61;&#160;0&#46;04&#59; p&#160;&#61;&#160;0&#46;60&#41;&#44; while high levels of agreement were reached for medial hinge loss &#40;Kappa&#160;&#61;&#160;0&#46;79&#59; p &#60; 0&#46;001&#41; and binary classification &#40;Kappa&#160;&#61;&#160;0&#46;62&#59; p &#60; 0&#46;001&#41;&#46; To assess the risk for necrosis&#44; the patients were grouped as high- and low-risk&#46; After grouping&#44; the agreement between the observers increased &#40;Kappa&#160;&#61;&#160;0&#46;86&#59; p &#60; 0&#46;001&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a> lists the Kappa data&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia><p id="para0032" class="elsevierStylePara elsevierViewall">Humeral head evolves to osteonecrosis in&#160;7&#160;&#40;17&#46;9&#37;&#41; patients&#46; The mean time to onset of necrosis was&#160;14&#46;1 &#177; 3&#46;9&#160;months &#40;range&#58;&#160;3&#8211;18&#160;months&#41;&#46; Two patients developed humeral head necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#41; without collapse&#44; while&#160;5&#160;patients had a collapse&#46; Screw migration due to necrosis occurred in&#160;3&#160;patients and the synthesis material had to be removed&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0033" class="elsevierStylePara elsevierViewall">The Kaplan-Meier curve showed a tendency toward an increased incidence of HHO after&#160;1&#160;year of surgical treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0002">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia><p id="para0034" class="elsevierStylePara elsevierViewall">The authors evaluated associations between factors including gender&#44; age&#44; trauma energy&#44; and time elapsed after fracturing with HHO and found no significant associations &#40;<a class="elsevierStyleCrossRef" href="#tbl0003">Table 3</a>&#41;&#46; The most common binary classification was the type&#160;12&#160;pattern &#40;<a class="elsevierStyleCrossRef" href="#tbl0004">Table 4</a>&#41;&#46; Binary patterns and additional Hertel criteria influenced the development of HHO &#40;<a class="elsevierStyleCrossRef" href="#tbl0004">Tables&#160;4</a>&#160;and&#160;<a class="elsevierStyleCrossRef" href="#tbl0005">5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><elsevierMultimedia ident="tbl0004"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="para0035" class="elsevierStylePara elsevierViewall">On the basis of the factors that could increase the risk for HHO&#44; the authors divided the sample into two groups&#46; However&#44; the groups did not differ in terms of HHO development &#40;<a class="elsevierStyleCrossRef" href="#tbl0006">Table 6</a>&#41;&#46; Three cases had&#160;3&#160;risk factors for osteonecrosis and none of them developed this complication&#46;</p><elsevierMultimedia ident="tbl0006"></elsevierMultimedia></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Discussion</span><p id="para0036" class="elsevierStylePara elsevierViewall">Humeral head osteonecrosis is one of the most frequent complications following osteosynthesis of proximal humerus fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> In this study&#44; the authors observed a prevalence of&#160;17&#46;9&#37;&#44; similar to that reported by Greiner et&#160;al&#46;&#44; who evaluated a similar cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> The prevalence of HHO after osteosynthesis ranges from&#160;4&#37;&#8211;30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0037" class="elsevierStylePara elsevierViewall">In terms of demographic characteristics&#44; the authors observed a higher prevalence of fractures in females &#40;56&#46;4&#37;&#41; and the elderly &#40;58&#46;4 &#177; 12&#160;years&#41;&#44; which is in agreement with the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0013"><span class="elsevierStyleSup">13</span></a> The authors did not find any influence of sex and age on the development of HHO&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0038" class="elsevierStylePara elsevierViewall">The time duration between trauma and surgery was longer in patients who developed HHO&#46; However&#44; it did not influence the development of osteonecrosis&#44; which is also in agreement with the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0012"><span class="elsevierStyleSup">12</span></a> Despite some controversy&#44; most clinicians agree that the posterior circumflex artery provides the main arterial supply to the proximal end of the humerus after a fracture&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> It is possible that preservation of the posterior circumflex artery reduces the risk of HHO&#44; and that the time duration between the trauma and the surgery does not influence the biological viability of the humeral head&#46; The authors always avoid extending the dissection and muscle retractions in order to decrease the risk of arterial damage and a chance of HHO&#46;</p><p id="para0039" class="elsevierStylePara elsevierViewall">Some authors have investigated and classified fracture patterns&#46; Hertel developed a classification system with criteria to predict HHO risk&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> The authors found a high concordance of the Hertel classification &#8211; Kappa&#160;&#61;&#160;0&#46;62&#59; p &#8804; 0&#46;001 &#40;except for the posteromedial head extension criterion less than or equal to&#160;8&#160;mm &#8211; Kappa&#160;&#61;&#160;0&#46;04&#59; p&#160;&#61;&#160;0&#46;6&#41; between observers&#44; as described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0014"><span class="elsevierStyleSup">14</span></a></p><p id="para0040" class="elsevierStylePara elsevierViewall">Despite the high level of agreement in terms of the Hertel classification and criteria between observers&#44; the system was not able to predict the risk for HHO&#46; Even after grouping the factors&#44; there was no difference in the incidence of HHO between the groups&#46; The present study&#39;s hypothesis for the divergence from the Hertel classification is that dissections lateral to the humeral head interfere less with medial vascularization&#44; which could reduce the risk of HHO despite the loss of the medial hinge and fragments extending to a head smaller than&#160;8&#160;mm&#46;</p><p id="para0041" class="elsevierStylePara elsevierViewall">Campochiaro et&#160;al&#46; observed that Hertel&#39;s criteria were not sufficient to determine the risk of developing osteonecrosis&#44; which is similar to the present findings&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> However&#44; Hertel has demonstrated that factors including medial hinge loss could increase the risk of osteonecrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a></p><p id="para0042" class="elsevierStylePara elsevierViewall">Most studies have assessed HHO in patients who underwent osteosynthesis through a deltopectoral approach&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a> The question of whether the surgical approach &#40;deltopectoral or anterolateral&#41; is related to the development of HHO remains controversial&#46;<a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a> A few studies have explored the incidence of HHO after the post-anterolateral approach&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> A systematic review by Cochrane was not able to determine whether the approach &#40;deltopectoral or anterolateral&#41; could influence the development of HHO because of the small number of studies related to the anterolateral approach&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> Another difficulty is that most studies evaluating the anterolateral approach have used the minimally invasive plate osteosynthesis technique&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> Therefore&#44; to our knowledge&#44; this is the first study to correlate the Hertel classification with the risk of HHO after osteosynthesis performed through the anterolateral approach&#46;</p><p id="para0043" class="elsevierStylePara elsevierViewall">The main limitation of the study was the retrospective design&#44; which did not allow comparisons with controls&#46; However&#44; the minimum follow-up period of&#160;1&#160;year after surgery&#44; and the uniform performance of the anterolateral approach&#44; strengthen the present findings&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Conclusion</span><p id="para0044" class="elsevierStylePara elsevierViewall">Hertel&#39;s criteria were not able to predict the risk for HHO after osteosynthesis of proximal humeral fractures performed through the anterolateral approach&#46; The overall prevalence of HHO was&#160;17&#46;9&#37;&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "titulo" => "Abstract"
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          "titulo" => "Introduction"
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          "titulo" => "Objectives"
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    "fechaRecibido" => "2022-09-24"
    "fechaAceptado" => "2023-02-08"
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    "highlights" => array:2 [
      "titulo" => "Highlights"
      "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><p id="spara009" class="elsevierStyleSimplePara elsevierViewall"><ul class="elsevierStyleList" id="celist0001"><li class="elsevierStyleListItem" id="celistitem0001"><span class="elsevierStyleLabel">&#8226;</span><p id="para0001" class="elsevierStylePara elsevierViewall">Proximal humeral fractures can progress to humeral head osteonecrosis</p></li><li class="elsevierStyleListItem" id="celistitem0002"><span class="elsevierStyleLabel">&#8226;</span><p id="para0002" class="elsevierStylePara elsevierViewall">It&#39;s controversial if the Hertel classification can predict humeral head osteonecrosis&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0003"><span class="elsevierStyleLabel">&#8226;</span><p id="para0003" class="elsevierStylePara elsevierViewall">Proximal Humeral Fractures can be fixed through the anterolateral approach&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0004"><span class="elsevierStyleLabel">&#8226;</span><p id="para0004" class="elsevierStylePara elsevierViewall">Objective&#58; to correlate the Hertel&#39;s predictors with the humeral head osteonecrosis&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0005"><span class="elsevierStyleLabel">&#8226;</span><p id="para0005" class="elsevierStylePara elsevierViewall">Hertel&#39;s criteria were not able to predict the risk for humeral head osteonecrosis&#46;</p></li><li class="elsevierStyleListItem" id="celistitem0006"><span class="elsevierStyleLabel">&#8226;</span><p id="para0006" class="elsevierStylePara elsevierViewall">The overall prevalence humeral head osteonecrosis was&#160;17&#46;9&#37;&#46;</p></li></ul></p></span>"
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    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Background</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">Proximal humeral fractures can progress to osteonecrosis of the humeral head&#46; Hertel developed a binary classification system &#40;12&#160;subtypes&#41; and demonstrated that some patterns have more risk to develop osteonecrosis&#46; Hertel described the prevalence and the risk factors for Humeral head osteonecrosis after osteosynthesis using a Deltopectoral approach&#46; Few studies have evaluated the prevalence and the capacity of Hertel&#39;s classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach&#46; The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk of developing osteonecrosis and its prevalence after osteosynthesis using the anterolateral approach&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Methods</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach&#46; Patients were divided into two groups&#58; high risk for necrosis &#40;group&#160;1&#41; and low risk for necrosis &#40;group&#160;2&#41; according to Hertel&#39;s criteria&#46; The overall prevalence of osteonecrosis and the prevalence in each group were calculated&#46; A radiological examination was performed in the true anteroposterior &#40;Grashey&#41;&#44; scapular&#44; and axillary views&#44; before and after the operation &#40;minimum&#160;1 year after surgery&#41;&#46; A Kaplan-Meier curve was used to assess the pattern of the temporal evolution of osteonecrosis&#46; The groups were compared using the Chi-square test or Fisher&#39;s exact test&#46; The unpaired <span class="elsevierStyleItalic">t</span>-test &#40;parametric variables &#8211; age&#41; and the Mann-Whitney test &#40;non-parametric time between trauma and surgery&#41; were used&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Results</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">In total&#44; 39&#160;patients were evaluated&#46; The postoperative follow-up time was&#160;14&#46;5 &#177; 3&#46;3&#160;months&#46; The time to onset of necrosis was&#160;14&#46;1 &#177; 3&#46;9&#160;months&#46; Sex&#44; age&#44; and time between trauma and surgery did not influence the risk of necrosis&#46; Type&#160;2&#44; 9&#44; 10&#44; 11&#44; and&#160;12&#44; or fractures with posteromedial head extension less than or equal to&#160;8&#160;mm&#44; or diaphysis deviation greater than&#160;2&#160;mm&#44; as well as grouping did not influence the risk for osteonecrosis&#46;</p></span> <span id="abss0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0006">Conclusions</span><p id="spara013" class="elsevierStyleSimplePara elsevierViewall">Hertel&#39;s criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach&#46; The total prevalence of osteonecrosis was&#160;17&#46;9&#37;&#160;with a tendency toward an increased incidence after&#160;1&#160;year of surgical treatment&#46;</p></span>"
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          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Radiographs showing initial fracture &#40;a&#41;&#59; one day after the surgery &#40;b&#41;&#59; six months after the surgery with radiological evidence of HHO &#40;c&#41;&#46;</p>"
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                  \t\t\t\t</td><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Medial hinge loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Binary classification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">High-risk group<a class="elsevierStyleCrossRef" href="#tb2fn2"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab3639428.png"
              ]
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            0 => array:3 [
              "identificador" => "tb2fn1"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="notep0001">Fracture extension to head smaller than&#160;8&#160;mm&#46;</p>"
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            1 => array:3 [
              "identificador" => "tb2fn2"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="notep0002">Risk of necrosis&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara004" class="elsevierStyleSimplePara elsevierViewall">Interobserver kappa test for the Hertel classification&#46;</p>"
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0003"
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        "tabla" => array:2 [
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0030"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0031"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Presence of osteonecrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0032"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Absence of osteonecrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0033"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">p-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Trauma Energy&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;00<a class="elsevierStyleCrossRef" href="#tb3fn1"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">10 &#40;25&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5 &#40;12&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">22 &#40;56&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Sex&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0049"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;20<a class="elsevierStyleCrossRef" href="#tb3fn1"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0050"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0051"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0052"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">20 &#40;51&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5 &#40;12&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">12 &#40;30&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Age &#40;average&#47;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">53&#46;8 &#177; 17&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">59&#46;4 &#177; 11&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;27<a class="elsevierStyleCrossRef" href="#tb3fn2"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Trauma-to-surgery &#40;Median&#47;min&#8211;max&#41;&#44; days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">8 &#40;1&#8211;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6 &#40;1&#8211;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;0<a class="elsevierStyleCrossRef" href="#tb3fn1"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
              "identificador" => "tb3fn1"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="notep0003">Fisher&#39;s exact test&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tb3fn2"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="notep0004">Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#46; <span class="elsevierStyleSup">c</span>Mann-Whitney <span class="elsevierStyleItalic">U</span> test &#40;in days&#41;&#46;</p>"
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        ]
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          "en" => "<p id="spara005" class="elsevierStyleSimplePara elsevierViewall">Correlations between variables and osteonecrosis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0066"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Binary pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0067"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Presence of osteonecrosis &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0068"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Absence of osteonecrosis &#40;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0069"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">p-value<a class="elsevierStyleCrossRef" href="#tb4fn1"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0072"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0077"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0078"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0081"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0083"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0085"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            0 => array:3 [
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              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="notep0005">Fisher&#39;s exact test&#59; &#40;n&#41; total number of patients&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara006" class="elsevierStyleSimplePara elsevierViewall">Binary Hertel classification and association with osteonecrosis&#46;</p>"
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0086"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0087"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Presence of osteonecrosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Absence of osteonecrosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">3 &#40;7&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">17 &#40;43&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0097"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0098"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">4 &#40;10&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0100"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">15 &#40;38&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Head extension &#60;8&#160;mm&#44; n&#160;&#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0106"></a><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25 &#40;64&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0109"></a><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">2 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">7 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">32 &#40;82&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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              "referencia" => array:1 [
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                    0 => array:2 [
                      "titulo" => "Shoulder osteonecrosis&#58; pathogenesis&#44; causes&#44; clinical evaluation&#44; imaging&#44; and classification"
                      "autores" => array:1 [
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                          "autores" => array:3 [
                            0 => "P&#46; Hernigou"
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                            0 => "S&#46; Brorson"
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                  "contribucion" => array:1 [
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                      "titulo" => "Displaced proximal humeral fractures&#46; I&#46; Classification and evaluation"
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                        0 => array:2 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                            1 => "A&#46; Hempfing"
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ISSN: 18075932
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