Locking Plate Combined With Endosteal Fibular Allograft Augmentation for Medial Column Comminuted Proximal Humeral Fracture

Abstract

The goal of this study was to evaluate the role of endosteal fibular allografts in the treatment of medial column comminuted proximal humerus fractures with a locking plate. The authors retrospectively analyzed the clinical outcomes of 63 patients (21 men and 42 women) who had proximal humerus fractures with a comminuted medial column and were treated at Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China, with a locking plate, either alone or in combination with a fibular strut allograft, between January 2013 and May 2017. Patients were divided into 2 groups: locking plate combined with fibular allograft (41 patients) and locking plate alone (22 patients). After an average follow-up of 16.3 months, all fractures were healed. Statistically significant differences were seen between the 2 groups in changes in the neck-shaft angle, humeral head height ( P <.001), and overall incidence of complications ( P <.05). However, no statistically significant difference was found in the Constant-Murley score. The use of a locking plate in combination with intramedullary fibular allograft augmentation can help to maintain reduction and reduce postoperative complications in the treatment of proximal humerus fractures that are complicated by medial column comminution. [ Orthopedics . 2020;43(6):367–372.]

Effect of Fibular Allograft Augmentation in Medial Column Comminuted Proximal Humeral Fractures

“…Contrary to the prior hypothesis, our findings suggest that the likelihood of a clinically relevant benefit is small at 12 months, because the 95% CI typically excluded the MCID (10 points for the DASH score). This is supported by 3 previous studies [24][25][26] , but is inconsistent with others as well as a meta-analysis 7,10,13,27 . The discrepancies could be partially explained by heterogeneity in the study populations; most of the studies were designed to include elderly patients with displaced fractures and only 1 study focused on medial column comminuted fractures 7 , even though fractures with medial column comminution should be the typical cases in which additional medial supports are likely to be required.…”

“…This is supported by 3 previous studies [24][25][26] , but is inconsistent with others as well as a meta-analysis 7,10,13,27 . The discrepancies could be partially explained by heterogeneity in the study populations; most of the studies were designed to include elderly patients with displaced fractures and only 1 study focused on medial column comminuted fractures 7 , even though fractures with medial column comminution should be the typical cases in which additional medial supports are likely to be required. Furthermore, no randomized allocation or appropriate casecontrol matching was conducted, meaning that the intergroup comparability was questionable in previous studies.…”

“…restoration of the medial column could be an important reason for postoperative screw penetration, varus deformity, and fixation failure [3][4][5] . This is supported by the finding that providing additional medial support is potentially associated with better clinical outcomes, especially in patients with medial column comminution [6][7][8][9][10][11] . One often-proposed strategy for providing medial support is using a segment of fibular allograft (FA), which is placed endosteally to provide additional medial support along with a laterally placed LP 12 .…”

“…All patients provided written informed consent. Medial column comminution was defined as fracture of the medial column with ‡3 fragments, as described in previous literature 7,15,16 .…”

Effects of fibular strut augmentation for the open reduction and internal fixation of proximal humeral fractures: a systematic review and meta-analysis

“…The measurement scales used in each trial varied, and most studies used more than one scale to assess the postoperative function, including the Constant score/Constant–Murley score (CMS) [ 22 ], American Shoulder and Elbow Surgeons (ASES) score [ 23 ], disability of arm–shoulder–hand (DASH) score [ 24 ], and Simple Shoulder Test (SST) [ 25 ]. After excluding two studies without sufficient data for the analysis [ 9 , 20 ], data syntheses were conducted based on six studies [ 10 , 16 – 19 , 21 ] and showed statistically significant differences in functional recovery in favour of the application of FSA (CMS: MD 5.07; 95% CI 3.40–6.74; I 2 = 0.00%; 95% PI 2.361–7.78; ASES: MD 5.08; 95% CI 3.67–6.49; I 2 = 0.00%; 95% PI 1.98–8.18), without obvious evidence of heterogeneity (Fig. 3 ).…”