Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures

Abstract

BackgroundCement augmentation (CA) of humeral head screws in locked plating of proximal humeral fractures (PHF) was found to be biomechanically beneficial. However, clinical outcomes of this treatment have not been well evaluated to date.ObjectivesTo assess outcomes of locked plating of PHF with additional CA and to compare them with outcomes of conventional locked plating without CA.Methods24 patients (mean age, 74.2 ± 10.1 years; 22 female) with displaced PHF were prospectively enrolled and treated with locked plating and additional CA. The Constant score (CS), the Simple Shoulder Test (SST), and the Simple Shoulder Value (SSV) were assessed 3 and 12 months postoperatively. Fracture healing and potential complications were evaluated on postoperative radiographs. The CS and complications were compared with the outcomes of a matched group of 24 patients (mean age, 73.9 ± 9.4 years; 22 female) with locked plating of displaced PHF without CA.ResultsAt the 3‑month follow-up, the mean CS was 59.9 ± 15.6 points, the mean SST was 7.5 ± 2.7 points, and the mean SSV was 63.9 ± 21.7%. All scores significantly improved by the 12-month follow-up (p < 0.05; CS, 72.9 ± 17.7; SST, 9.2 ± 3.2; SSV, 77.2 ± 17.3%). There were two cases (8%) of biological complications (n = 1 varus malunion and n = 1 humeral head necrosis). Compared with locked plating without CA, no significant differences were observed between the CS at the 3‑ (57.8 ± 13.4 points; p = 0.62) and 12-month (73.0 ± 12.8 points; p = 0.99) follow-up. However, patients without CA had a significantly increased risk of early loss of reduction and articular screw perforation (p = 0.037).ConclusionLocked plating of proximal humeral fractures with trauma cement augmentation of humeral head screws could be translated from the ex-vivo lab setting into the clinical situation without additional complications. Locked plating of displaced PHF with additional cement augmentation showed similar clinical outcomes but reduced the rate of early implant-related complications compared to locked plating without additional CA.

Cement augmentation of the proximal humerus internal locking system in elderly patients: a multicenter randomized controlled trial

“…This could be due to the prospective nature of the study and a more comprehensive collection of AEs. Consistent to a previous report that no additional complications were noted in screw augmentation in PHF [ 27 ], in the current study, only one patient suffered an AE related to the used Traumacem V + cement, i.e., intraoperative cement leakage into the shoulder joint. After a joint arthrotomy, the patient fully recovered.…”

“…With the highest mean age (76.8 ± 6.8) recorded in the PHF surgery literature so far [ 15 , 27 ] and a very low BMD of 87.2 ± 20 [ 17 , 48 ], the current study nevertheless achieved an overall mechanical failure rate of around 15%. Although it is difficult to compare our mechanical failure rate with literature values due to the reporting heterogeneity, the current mechanical failure rate is likely to be on the lower end of what have been reported [ 4 , 14 , 20 , 23 , 27 , 49 ]. In osteoporotic fracture care, with the restoration of the medial hinge and intrinsic stability through anatomical reduction, implants become a load sharing rather than a load bearing construct leading to reduced mechanical failure rates.…”

“…Screw augmentation has been shown to be effective in biomechanical studies, but clinical evidence has been lacking. A recent study by Katthagen et al comparing 24 patients treated with PHILOS screw augmentation to a historical cohort showed that screw augmentation reduced the likelihood of early loss of reduction and articular screw perforation but resulted in no differences in shoulder function scores [ 27 ]. In contrast, the current study showed no overall differences between the treatment groups.…”

“…Biomechanical tests of the proximal humerus showed that augmentation of screw tips with polymethylmethacrylate (PMMA) cement improved the mechanical properties of the bone-implant complex, especially in low mineral density bones [ 24 – 26 ]. To date, there has been little clinical evidence supporting the benefit of PMMA augmentation of screw tips [ 27 – 29 ].…”

Biomechanics of Upper Extremity Double Plating

“…The main challenge for modern techniques of fracture fixation remains to achieve primary stability and anatomic reduction, especially in elderly patients with osteoporotic fractures [1]. Angle-stable (locking) plates and technical advances, such as cement augmentation of individual screws, have significantly widened the range of indications for surgical management during the last decade [2,3]. Primarily in cases with reduced bone quality, but also in cases with limited options for implant anchoring, stable fracture fixation can be difficult, even when modern implants are used.…”