A Novel Technique for Treatment of Metaphyseal Voids in Proximal Humerus Fractures in Elderly Patients

Abstract

Background and Objectives: The treatment of proximal humerus fractures in elderly patients is challenging, with reported high complication rates mostly related to implant failure involving screw cut-out and penetration. Metaphyseal defects are common in osteoporotic bone and weaken the osteosynthesis construct. A novel technique for augmentation with polymethylmethacrylate (PMMA) bone cement was developed for the treatment of patients in advanced age with complex proximal humerus fractures and metaphyseal voids, whereby the cement was allowed to partially cure for 5–7 min after mixing to achieve medium viscosity, and then it was manually placed into the defect through the traumatic lateral window with a volume of 4–6 mL per patient. The aim of this retrospective clinical study was to assess this technique versus autologous bone graft augmentation and no augmentation. Materials and Methods: The outcomes of 120 patients with plated Neer three- and four-part fractures, assigned to groups of 63 cases with no augmentation, 28 with bone graft augmentation and 29 with cement augmentation, were assessed in this study. DASH, CS, pain scores and range of motion were analyzed at 3, 6 and 12 months. Statistical analysis was performed with factors for treatment and age groups, Neer fracture types and follow-up periods, and with the consideration of age as a covariate. Results: DASH and CS improved following cement augmentation at three and six months compared to bone grafting, being significant when correcting for age as a covariate (p ≤ 0.007). While the age group had a significant effect on both these scores with worsened values at a higher age for non-augmented and grafted patients (p ≤ 0.044), this was not the case for cement augmented patients (p ≥ 0.128). Cement augmentation demonstrated good clinical results at 12 months with a mean DASH of 10.21 and mean CS percentage of 84.83% versus the contralateral side, not being significantly different among the techniques (p ≥ 0.372), despite the cement augmented group representing the older population with more four-part fractures. There were no concerning adverse events specifically related to the novel technique. Conclusions: This study has detailed a novel technique for the treatment of metaphyseal defects with PMMA cement augmentation in elderly patients with complex proximal humerus fractures and follow-up to one year, whereby the cement was allowed to partially cure to achieve medium viscosity, and then it was manually placed into the defect through the traumatic lateral window. The results demonstrate clinically equivalent short-term results to 6 months compared to augmentation with bone graft or no augmentation—despite the patient group being older and with a higher rate of more severe fracture patterns. The technique appears to be safe with no specifically related adverse events and can be added in the surgeon’s armamentarium for the treatment of these difficult to manage fractures.

Combined Humeral Head and Shaft Fractures: Outcome Following Intramedullary Nailing and Plating

“…Nowadays, more advanced implants are available for treatment of complex proximal humerus fractures. Especially, cement augmentation and bone grafting of osteoporotic fractures as well as advanced implant designs enhancing better stability were developed [ 22 , 23 , 24 , 25 ]. It would be interesting to investigate patients with FHS after fracture stabilization with such implants in future studies.…”

Treatment of Metaphyseal Defects in Plated Proximal Humerus Fractures with a New Augmentation Technique—A Biomechanical Cadaveric Study

“…In the augmented group, six-milliliter cement with medium viscosity (TRAUMACEM TM V+, DePuy Synthes, Raynham, MA, USA; chemical composition: 45.0% PMMA, 40.0% zirconium dioxide, 14.5% hydroxyapatite, 0.5% benzoyl peroxide [ 25 ]; seven minutes after mixing) was placed manually through the lateral window in the defect of the humerus head fragment after its anatomical reduction to the shaft and prior to the anatomical reduction of the GT fragment in a manner resembling clinical practice [ 23 ].…”

“…A new augmentation technique of plated complex PHFs with metaphyseal defects was recently introduced in clinical practice ( Figure 1 ) [ 23 ]. Nevertheless, the biomechanical competence of augmented plate fixation with this technique versus non-augmented plating has not been investigated so far.…”