Locking Plate Use with or without Strut Support for Varus Displaced Proximal Humeral Fractures in Elderly Patients

Abstract

Background:Varus displaced fractures of the proximal part of the humerus, particularly in osteoporotic bone, commonly require open reduction and internal fixation. However, surgical treatment methods remain controversial and have shown inconsistent results. A fibular allograft for indirect medial reduction and strut support has been used in an effort to prevent secondary postoperative varus displacement. However, the long-term outcomes of this method require confirmation. We hypothesized that placing a fibular strut parallel to the calcar screw could increase the biomechanical stability of the medial hinge, thus preventing secondary varus deformity. In the present study, we compared the clinical outcomes of locking plate use with and without medial strut support with use of a fibular allograft for the treatment of varus humeral fractures in patients ≥65 years old.Methods:We compared 2 different graft techniques involving the use of fibular allografts in elderly patients with varus displaced proximal humeral fractures who underwent open reduction and internal fixation. The patients were divided into 3 groups: (1) the intramedullary graft group (Group A), (2) the medial hinge support group (Group B), and (3) the locking plate alone group (Group C). Clinical outcomes included the final varus angulation of the humeral head, the occurrence of major complications (screw cut-out or cut-through or osteonecrosis), and the American Shoulder and Elbow Surgeons (ASES) score at 1 year after treatment.Results:A total of 128 patients were included in our study. The final varus angles were 14.7°, 13.1°, and 18.6°, for the intramedullary graft group, the medial hinge support group, and locking plate alone group, respectively. The mean ASES scores were 87.2, 88.6, and 82.2, respectively. There were differences in ASES scores between Group A and Group C as well as also between Group B and Group C. Fewer major complications were found in patients managed with locking plates in combination with intramedullary graft or medial hinge support (Group A and Group B) than in patients managed with locking plates alone (Group C).Conclusions:The use of a locking plate in combination with medial strut support with use of a fibular allograft reduced complications when used for the treatment of varus displaced proximal humeral fractures in elderly patients in comparison with the use of a locking plate alone.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

“…1 ). Among them, one was a three-arm study including a group using another technique, and data from this group were not considered for statistical synthesis [ 20 ]. Finally, after excluding the cases lost to follow-up, data from 596 participants, with the average age ranging from 59.9 to 75.6 years and the average follow-up period ranging from 12 to 43 months, were collected and synthesized for the meta-analyses.…”

“…Considering that one patient might have more than one complication and that there would be a strong link between these complications (e.g. a patient might have had varus malunion or humeral head collapse that led to a screw perforation), the complication rate was calculated as the number of patients with complications in each group, which was reported in six studies [ 10 , 16 – 20 ]. Pooling the estimates confirmed a lower likelihood of the complication incidence associated with the application of FSA (OR 0.48; 95% CI 0.25–0.92; I 2 = 7.52%; 95% PI 0.16–1.45) (Fig.…”

Plate osteosynthesis of proximal humerus fractures: treatment options and technical advancements

“…With the use of a strut graft, biomechanical studies demonstrated an increase in construct stiffness and failure load, reduced fragment motion and change in gap distance [69][70][71] , ultimately protecting from loss of reduction for varus collapse 72 . Good results in fractures with medial support loss have been obtained with this technique, with low loss of reduction 67,68,73,74 and better results compared to non-augmented constructs 68,74 .…”

Effect of surgical approaches on deltoid innervation and clinical outcomes in the treatment of proximal humeral fractures

“…This prospective case-control study included patients who underwent osteosynthesis with proximal humeral anatomic locking plate (TST Orthopedics, Istanbul, Turkey) for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 11 proximal humeral fractures[ 3 ] (56 patients) in Health Sciences University, Baltalimani Bone and Joint Diseases Training and Research Hospital between January 2015 and June 2016. The exclusion criteria were preoperative nerve deficit (one patient), open fracture, accompanying dislocation (two patients), pathological fracture, history of previous surgery, or fracture from the affected extremity.…”