Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies
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Secondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies.
Materials and methods
The databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively.
Out of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II–IV and study quality was 26–70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients’ clinical outcome. None of the studies showed relevant augmentation-associated complication rates.
Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs’ stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.
KeywordsHumerus Augmentation Cement Allograft Autograft
There is no funding source.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 3.Kralinger F, Blauth M, Goldhahn J, Kach K, Voigt C, Platz A, Hanson B (2014) The influence of local bone density on the outcome of one hundred and fifty proximal humeral fractures treated with a locking plate. J Bone Joint Surg Am 96(12):1026–1032. https://doi.org/10.2106/JBJS.M.00028 CrossRefGoogle Scholar
- 5.Haasters F, Prall WC, Himmler M, Polzer H, Schieker M, Mutschler W (2015) Prevalence and management of osteoporosis in trauma surgery. Implementation of national guidelines during inpatient fracture treatment. Unfallchirurg 118(2):138–145. https://doi.org/10.1007/s00113-013-2500-4 CrossRefGoogle Scholar
- 7.Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 20(7):1025–1033. https://doi.org/10.1016/j.jse.2011.04.016 CrossRefGoogle Scholar
- 8.Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C, Torgerson D, Collaborators PT (2015) Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 313(10):1037–1047. https://doi.org/10.1001/jama.2015.1629 CrossRefGoogle Scholar
- 11.Tepass A, Blumenstock G, Weise K, Rolauffs B, Bahrs C (2013) Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland. J Shoulder Elbow Surg 22(1):e8–e14. https://doi.org/10.1016/j.jse.2012.04.002 CrossRefGoogle Scholar
- 16.Ockert B, Biermann N, Haasters F, Mutschler W, Braunstein V (2013) Reverse shoulder arthroplasty for primary fracture treatment. Displaced three and four part fractures of the proximal humerus in the elderly patient. Unfallchirurg 116(8):684–690. https://doi.org/10.1007/s00113-013-2410-5 CrossRefGoogle Scholar
- 18.Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 10(1):2–11CrossRefGoogle Scholar
- 19.Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M (2010) Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech (Bristol Avon) 25(7):642–646. https://doi.org/10.1016/j.clinbiomech.2010.04.006 CrossRefGoogle Scholar
- 20.Osterhoff G, Baumgartner D, Favre P, Wanner GA, Gerber H, Simmen HP, Werner CM (2011) Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. J Shoulder Elbow Surg 20(5):740–746. https://doi.org/10.1016/j.jse.2010.10.040 CrossRefGoogle Scholar
- 21.Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC (2011) The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Jt Surg Br 93(7):937–941. https://doi.org/10.1302/0301-620X.93B7.26125 CrossRefGoogle Scholar
- 24.Katthagen JC, Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H (2014) Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures. Clin Biomech (Bristol Avon) 29(7):735–741. https://doi.org/10.1016/j.clinbiomech.2014.06.008 CrossRefGoogle Scholar
- 30.Kathrein S, Kralinger F, Blauth M, Schmoelz W (2013) Biomechanical comparison of an angular stable plate with augmented and non-augmented screws in a newly developed shoulder test bench. Clin Biomech (Bristol Avon) 28(3):273–277. https://doi.org/10.1016/j.clinbiomech.2012.12.013 CrossRefGoogle Scholar
- 32.Schliemann B, Seifert R, Rosslenbroich SB, Theisen C, Wahnert D, Raschke MJ, Weimann A (2015) Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures. J Shoulder Elbow Surg 24(12):1968–1973. https://doi.org/10.1016/j.jse.2015.06.028 CrossRefGoogle Scholar
- 33.Kuang GM, Wong TM, Wu J, Ouyang J, Guo H, Zhou Y, Fang C, Leung FKL, Lu W (2018) Augmentation of a locking plate system using bioactive bone cement-experiment in a proximal humeral fracture model. Geriatr Orthop Surg Rehabil 9:2151459318795312. https://doi.org/10.1177/2151459318795312 CrossRefGoogle Scholar
- 36.Zhu L, Liu Y, Yang Z, Li H, Wang J, Zhao C, Chen X, Zhang Y (2014) Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture. Chin Med J (Engl) 127(9):1672–1676Google Scholar
- 40.Rollo G, Rotini R, Pichierri P, Giaracuni M, Stasi A, Macchiarola L, Bisaccia M, Meccariello L (2017) Grafting and fixation of proximal humeral aseptic non union: a prospective case series. Clin Cases Miner Bone Metab 14(3):298–304. https://doi.org/10.11138/ccmbm/2017.14.3.298 CrossRefGoogle Scholar
- 44.Little MT, Berkes MB, Schottel PC, Lazaro LE, LaMont LE, Pardee NC, Nguyen JT, Helfet DL, Lorich DG (2014) The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma 28(6):338–347. https://doi.org/10.1097/BOT.0000000000000012 CrossRefGoogle Scholar
- 46.Hinds RM, Garner MR, Tran WH, Lazaro LE, Dines JS, Lorich DG (2015) Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation. J Shoulder Elbow Surg 24(6):889–896. https://doi.org/10.1016/j.jse.2014.10.019 CrossRefGoogle Scholar
- 51.Kim DS, Lee DH, Chun YM, Shin SJ (2018) Which additional augmented fixation procedure decreases surgical failure after proximal humeral fracture with medial comminution: fibular allograft or inferomedial screws? J Shoulder Elbow Surg 27(10):1852–1858. https://doi.org/10.1016/j.jse.2018.03.020 CrossRefGoogle Scholar
- 52.Chen H, Ji X, Gao Y, Zhang L, Zhang Q, Liang X, Tang P (2016) Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemi-arthroplasty for repair of osteoporotic four-part proximal humerus fracture: Consecutive, prospective, controlled, and comparative study. Orthop Traumatol Surg Res 102(3):287–292. https://doi.org/10.1016/j.otsr.2015.12.021 CrossRefGoogle Scholar
- 61.Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD (2012) Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg 21(6):741–748. https://doi.org/10.1016/j.jse.2011.09.017 CrossRefGoogle Scholar
- 62.Russo R, D’Auria D, Ciccarelli M, Della Rotonda G, D’Elia G, Siciliano B (2017) Triangular block bridge method for surgical treatment of complex proximal humeral fractures: theoretical concept, surgical technique and clinical results. Injury 48(Suppl 3):S12–S19. https://doi.org/10.1016/S0020-1383(17)30651-4 CrossRefGoogle Scholar