The Role of Medial Comminution and Calcar Restoration in Varus Collapse of Proximal Humeral Fractures Treated with Locking Plates

Ponce, Brent A.; Thompson, Kevin J.; Raghava, Parthasarathy; Eberhardt, Alan W.; Tate, Janet P.; Volgas, David A.; Stannard, James P.

doi:10.2106/jbjs.k.00202

Cited by 89 publications

(75 citation statements)

References 39 publications

(54 reference statements)

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“…This may, in part, be explained by the ability to insert longer calcar screws when the plate is more proximally positioned, and/or by the presumption that more of the calcar screw threads are located in the fracture fragments and/or in higher density bone, though these aspects were not investigated in the current study. The importance of calcar screws has been shown biomechanically and computationally in previous studies, and retrospectively in clinical reviews; this study's findings add to their justification by showing that these screws directly and indirectly support the function of other screws within the constructs. These findings could encourage surgeons to prioritize the placement of calcar screws over others, given their dominant role in reducing failure risk.…”

Section: Discussionsupporting

confidence: 56%

Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations

Fletcher

Windolf

Richards

et al. 2019

Journal Orthopaedic Research

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Multifragmented proximal humeral fractures frequently require operative fixation. The locking plates commonly used are often placed relative to the greater tuberosity, however no quantitative data exists regarding the effect of positional changes. The aim of the study was to establish the effects from variations in proximal‐distal PHILOS humeral plate positioning on predicted fixation failure risk. Twenty‐one left‐sided low‐density virtual humeri models were created with a simulation framework from CT data of elderly donors and osteotomized to mimic an unstable three‐part malreduced AO/OTA 11‐B3.2 fracture with medial comminution. A PHILOS plate with either four or six proximal screws was used for fixation. Both configurations were modelled with plate repositioning 2 and 4 mm distally and proximally to its baseline position. Applying a validated computational model, three physiological loading situations were simulated and fixation failure predicted using average strain around the proximal screws—an outcome established as a surrogate for cycles to failure. Varying the craniocaudal plate position affected the peri‐implant strain for both four and six‐screw configurations. Even though significant changes were seen only in the latter, all tests suggested that more proximal plate positioning results in decreased peri‐screw strains whereas distalizing creates increases in strain. These results suggest that even a small distal PHILOS plate malpositioning may reduce fixation stability. Plate distalization increases the probability of being unable to insert all screws within the humeral head, which dramatically increases the forces acting on the remaining screws. Proximal plate shifting may be beneficial, especially for constructs employing calcar screws. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res

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Section: Discussionsupporting

confidence: 56%

Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations

Fletcher

Windolf

Richards

et al. 2019

Journal Orthopaedic Research

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“…The average neck-shaft angle after surgery in the presence of medial calcar injury indicates increased tendency of varus, but was still within normal range. Similarly, Ponce et al 20) used locked plates to treat proximal humerus fracture and reported tendencies of varus in the presence of medial calcar injury, but also that this tendency could be decreased by recovering the calcar with a screw. The period of bone union was different between the two groups, on average 6.79 weeks (SD 1.606) and 8.65 weeks (SD 2.167) in G1 and G2, respectively (p < 0.05).…”

Section: Discussionmentioning

confidence: 99%

Treatment of Proximal Humeral Fracture Using Polarus Nail and Philos Plate

Choi¹,

Sim²,

Lee³

et al. 2014

Clin Shoulder Elbow

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Background: To compare the treatment of the proximal humerus fracture using a Polarus nail or Philos plate, we aimed to analyze the functional recovery and the factors affecting the selection between the two types of surgery. Methods: The study included 107 patients with proximal humerus fracture who underwent surgery at our institution. Of these patients, 67 underwent surgery with Polarus nails (G1) and 40 with Philos plates (G2). In G1, the cases of two-and three-part fractures were 60 and 7 cases, in G2, the cases of two-, three-, and four-part fractures were 28, 10, and 2 cases, respectively. The average age was 61 years old, and the average follow-up period was 32.5 months. We compared radiological results, the functional recovery retrospectively. Results: The radiological union time was 6.8 weeks and 8.7 weeks on average in G1 and G2 (p < 0.05). At the one-year follow-up period, these were visual analogue scale (VAS) 1.355, forward flexion (FF) 130.968, external rotation (ER) 50.161, internal rotation (IR) L2 in G1, and VAS 0.781, FF 135.806 ER 51.25, IR L1 in G2, respectively, showing no significant differences between the two groups (p > 0.05). Similar observations were made at the final follow-up. In terms of functional recovery, no significant differences were seen at the one-year or at the final follow-up period (p > 0.05). Conclusions: For the surgical treatment of proximal humeral fracture, the selection of the type of surgery is affected by the fracture pattern. However, both methods give satisfactory outcomes and do not show significant differences in the functional outcome after the surgery. (Clin Shoulder Elb 2014;17(3):120-126)

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“…It is stated that, the angular stable implant was responsible for screws cutting through osteoporotic humeral heads in elder patients and, was stated as 46% over 65 years old patients [5,21,24]. Anatomic reduction and restoration of the medial cortical support are crucial in order to prevent secondary varus angulation [14,26,27]. In the present study secondary varus angulation occurred in 2 without screw cut-out (Figure 1), where anatomic reduction was achieved and medial support screws were placed but tension band wiring was not performed.…”

Section: Discussionmentioning

confidence: 99%

“…There is a certain consensus on prosthetic replacement of head -split fractures, but out of these, in 3 and 4-part fractures the surgical management based on personal experience [5]. By the introduction of locking plates there used to be a substantial rise in the osteosynthesis of the 3 and 4-part proximal humeral fractures [2,7,[10][11][12][13][14]. These plates have some advantages over conventional plates such as, providing high stability allowing early rehabilitation because of angular stable construction and multidirectional locking screws anchored in humeral head, with less dissection of soft tissue and less compromising of periosteal vascularization [2,[15][16][17].…”

mentioning

confidence: 99%

“…These plates have some advantages over conventional plates such as, providing high stability allowing early rehabilitation because of angular stable construction and multidirectional locking screws anchored in humeral head, with less dissection of soft tissue and less compromising of periosteal vascularization [2,[15][16][17]. Also, locking plates have superior biomechanical properties under rotational loads than locking intramedullary nails [12,14,18,19]. These specifications made them the preferred choice for the treatment of proximal humeral fractures in elderly, particularly those with osteoporosis [3,4,15,16].…”

mentioning

confidence: 99%

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Surgical Management of 3 and 4-Part Proximal Humerus Fractures with Locking Plates in Elderly

Kovalak¹

2017

Ann Clin Anal Med

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ÖzetAmaç: Proksimal humerus kırıkları tüm kırıkların yaklaşık %5'ini oluşturur ve bunların da %15-20'si deplase ve dengesizdir. Kilitli plakların ortaya çıkma-sından sonra bu kırıkların osteosentez ile tedavisinde artış olmuştur. Ancak, hala bu kompleks kırıkların tedavisinde bir fikir birliği oluşmamıştır. Bu retrospektif çalışma ile yaşlılarda 3 ve 4-parçalı proksimal humerus kırıklarının kilitli plakla osteosentezinin fonksiyonel sonuçları ve prognozu etkileyen faktörleri değerlendirmeyi amaçladık. Gereç ve Yöntem: Çalışmaya 2010-2015 yılları arasında deplase, 3 ve 4 parçalı proksimal humerus kırığı tanısıyla kilitli plak ile osteosentez yapılan 53 hasta dahil edildi. Kırıkların sınıflaması Neer Sınıflama sistemine göre yapıldı. Sonuçlar, Constant-Murley Skorlama sistemi (CMS), görsel analog ağrı ölçeği, ve düz radyografi ile değerlendirildi. Hareket açıklığının değerlendirilmesi amacı ile kolun öne elevasyonu ve abduksiyonu ölçüldü. Bulgular: 3 ve 4 parçalı kırıklar arasında, CMS, öne elevasyon ve abdüksiyonda istatiksel olarak bir fark saptanmadı (p>0.05). Ağrı 4 parçalı kırıklarda belirgin olarak daha fazla idi (p=0.035). CMS, öne elevasyon ve abduksiyon, yaş ve cerrahi süresinde gecikme ile ters yönde korale idi. Komplikasyon gelişen hastalar ile gelişmeyenler arasında CMS, öne elevasyon ve abduksiyonda istatiksel olarak anlamlı farklılık saptandı (p=0.029, p=0.017 and p=0.024). Tartışma: Proksimal humerus kırıklarının kilitli plak ile tespiti sonrasında fonksiyonel sonuçlar; hastaya ait faktörler, kırık yapısı, cerrah ve implanta bağlı olmak üzere birçok faktörle ilişkilidir. Endikasyonlar dikkatli seçil-diği takdirde 3 ve 4 parçalı proksimal humerus kırıklarının kilitli plaklarla osteosentezi iyi sonuçlar vermektedir. Anahtar KelimelerHumerus Kırıkları; Proksimal; Omuz Kırıkları; Kırık Sabitlenmesi; İnternal Abstract Aim: Proximal humeral fractures are approximately 5% of all fractures and, %15-20 is displaced and unstable. By the introduction of locking plates there used to be a substantial rise in the osteosynthesis of the 3 and 4-part proximal humeral fractures. But there is still a lack of consensus for the optimal treatment of these complex fractures. In this retrospective study, we aimed to evaluate the functional outcomes and prognostic factors of 3 and 4-part proximal humerus fractures treated with locking plate osteosynthesis in elderly. Material and Method: 53 patients with displaced 3 and 4-part proximal humeral fractures treated with locking plate osteosynthesis between 2010 and 2015 were included. The fractures were classified according to Neer classification system. Outcomes were assessed by Constant-Murley scoring system (CMS), visual analog pain scale and plain radiographs. In reference to range of motion, forward elevation and abduction of the arm were measured. Results: No statistically significant differences found between the 3-part and 4-part fractures in CMS, forward elevation and, abduction (p>0.05). Pain was significantly higher in 4-part fractures (p=0.035). CMS, forward elevati...

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The Role of Medial Comminution and Calcar Restoration in Varus Collapse of Proximal Humeral Fractures Treated with Locking Plates

Abstract: The data suggest that medial comminution is a predictor of poor stability of proximal humeral fractures and that stability may be improved through calcar restoration.

Cited by 89 publications

References 39 publications

Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations

Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations

Treatment of Proximal Humeral Fracture Using Polarus Nail and Philos Plate

Surgical Management of 3 and 4-Part Proximal Humerus Fractures with Locking Plates in Elderly

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