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Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies

  • Trauma Surgery
  • Published:
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Abstract

Introduction

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.

Results

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.

Conclusions

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.

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Authors and Affiliations

  1. Hospital of Trauma Surgery, University of Munich (LMU), Nussbaumstr. 20, 80336, Munich, Germany

    Niklas Biermann, Wolf Christian Prall, Wolfgang Böcker & Florian Haasters

  2. Academic Teaching Hospital of the Paracelsus Private Medical University Salzburg, Strubergasse 21, 5020, Salzburg, Austria

    Wolf Christian Prall, Hermann Otto Mayr & Florian Haasters

  3. Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center, Albert-Ludwigs-University of Freiburg, Freiburg, Germany

    Hermann Otto Mayr

  4. Department of Knee, Hip and Shoulder Surgery, Schön Klinik Munich-Harlaching, Harlachinger Str. 51, 81547, Munich, Germany

    Wolf Christian Prall, Hermann Otto Mayr & Florian Haasters

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Biermann, N., Prall, W.C., Böcker, W. et al. Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies. Arch Orthop Trauma Surg 139, 1075–1099 (2019). https://doi.org/10.1007/s00402-019-03162-2

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