Endosteal Strut Allograft Augmentation in the Osteosynthesis of Proximal Humerus Fractures
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Published:
Apr 18, 2022
Keywords:
Proximal humerus, surgical neck fracture, strut allograft, augmentation, locking plate, neck-shaft angle, humeral head height
Main Article Content
Abstract
Introduction: Proximal humeral fractures (PHF) are common, particularly in the elderly. Locking plate fixation continues to provide unpredictable outcomes. Medial hinge support plays a significant role in stability. We aim to evaluate the outcomes of plate fixation with endosteal strut allograft augmentation in PHFs.
Materials and Methods: We evaluated the clinical and radiological outcomes of 12 patients with PHF who were treated with plate fixation and strut allograft augmentation. The strut allograft was introduced into the humeral shaft to add support to the medial hinge. We compared the final follow-up radiographs to those taken immediately after surgery. We defined a loss of reduction if the change in Humeral Head Height or the Neck-Shaft Angle measured over 3 mm or 5°, respectively. The clinical evaluation included range of motion, Constant-Murley (CM) score, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), and return to daily activities.
Results: Twelve patients completed follow-up. The patients’ average age was 62.8. Ten patients healed without loss of reduction. Average CM and SSV scores were 82.1 and 80%, respectively, and average VAS was 1.9. Anterior elevation averaged 138.3°, external rotation 49.5°, and internal rotation at L3 level. The mean differences in HHH and NSA were 2.3 mm and 4.92°, respectively. We recorded no complications associated to the procedure.
Conclusion: Locking plate fixation with endosteal strut allograft augmentation is a reliable technique for the treatment of PHF. It provides support to the humeral neck and maintains reduction in fractures with disruption of the medial hinge.
Materials and Methods: We evaluated the clinical and radiological outcomes of 12 patients with PHF who were treated with plate fixation and strut allograft augmentation. The strut allograft was introduced into the humeral shaft to add support to the medial hinge. We compared the final follow-up radiographs to those taken immediately after surgery. We defined a loss of reduction if the change in Humeral Head Height or the Neck-Shaft Angle measured over 3 mm or 5°, respectively. The clinical evaluation included range of motion, Constant-Murley (CM) score, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), and return to daily activities.
Results: Twelve patients completed follow-up. The patients’ average age was 62.8. Ten patients healed without loss of reduction. Average CM and SSV scores were 82.1 and 80%, respectively, and average VAS was 1.9. Anterior elevation averaged 138.3°, external rotation 49.5°, and internal rotation at L3 level. The mean differences in HHH and NSA were 2.3 mm and 4.92°, respectively. We recorded no complications associated to the procedure.
Conclusion: Locking plate fixation with endosteal strut allograft augmentation is a reliable technique for the treatment of PHF. It provides support to the humeral neck and maintains reduction in fractures with disruption of the medial hinge.
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How to Cite
Altamirano, N., Gómez, D. J., Muratore, Álvaro, Teruya, G., Viollaz, G. M., Tedeschi, A., & Durán, R. (2022). Endosteal Strut Allograft Augmentation in the Osteosynthesis of Proximal Humerus Fractures. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 87(2), 207-218. https://doi.org/10.15417/issn.1852-7434.2022.87.2.1435
Section
Clinical Research
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References
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open reduction and internal fixation of proximal humerus fractures: a systematic review and the authors’ preferred surgical technique. Orthop J Sport Med 2016;4(7):1-9. https://doi.org/10.1177/2325967116656829
2. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87-92. https://doi.org/10.1097/01.blo.0000194672.79634.78
3. Resch H, Tauber M, Neviaser RJ, Neviaser SN, Majed A, Halsey T, et al. Classification of proximal humeral
fractures based on a pathomorphologic analysis. J Shoulder Elbow Surg 2016;25(3):455-62. https://doi.org/10.1016/j.jse.2015.08.006
4. Gupta AK, Harris JD, Erickson BJ, Abrams GD, Bruce B, McCormick F, et al. Surgical management of complex
proximal humerus fractures - A systematic review of 92 studies including 4500 patients. J Orthop Trauma 2015;
29(1):54-9. https://doi.org/10.1097/BOT.0000000000000229
5. Walsh S, Reindl R, Harvey E, Berry G, Beckman L, Steffen T. Biomechanical comparison of a unique locking
plate versus a standard plate for internal fixation of proximal humerus fractures in a cadaveric model. Clin Biomech (Bristol, Avon) 2006;21(10):1027-31. https://doi.org/10.1016/j.clinbiomech.2006.06.005
6. Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: A prospective multicenter analysis. J Orthop Trauma 2009;23(3):163-72. https://doi.org/10.1097/BOT.0b013e3181920e5b
7. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked
plating of proximal humerus fractures. J Orthop Trauma 2007;21(3):185-91. https://doi.org/10.1097/BOT.0b013e3180333094
8. Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani NC, Zuckerman JD. Early complications in proximal humerus
fractures (OTA types 11) treated with locked plates. J Orthop Trauma 2008;22(3):159-64. https://doi.org/10.1097/BOT.0b013e318169ef2a
9. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the
PHILOS plate: Early experience. Clin Orthop Relat Res 2006;(442):115-20. https://doi.org/10.1097/01.blo.0000194678.87258.6e
10. Ricchetti ET, Warrender WJ, Abboud JA. Use of locking plates in the treatment of proximal humerus fractures. J
Shoulder Elbow Surg 2010;19(2 Suppl):66-75. https://doi.org/10.1016/j.jse.2010.01.001
11. Lee CH, Huang KC, Hsiao CK, Cheng S, Liu YC, Chang CH. Biomechanical comparison of the role of inlay graft
in proximal humerus fracture fixed with conventional plate and locking plate. J Mech Med Biol 2013;13(4):1-8.
https://doi.org/10.1142/S0219519413500553
12. Katthagen JC, Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H. Biomechanical effects of calcar screws
and bone block augmentation on medial support in locked plating of proximal humeral fractures. Clin Biomech
(Bristol, Avon) 2014;29(7):735-41. https://doi.org/10.1016/j.clinbiomech.2014.06.008
13. Tingart MJ, Apreleva M, von Stechow D, Zurakowski D, Warner JJP. The cortical thickness of the proximal humeral diaphysis predicts bone mineral density of the proximal humerus. J Bone Joint Surg Br 2003;85(4):611-7.
https://doi.org/10.1302/0301-620x.85b4.12843
14. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res
1987;(214):160-4. PMID: 3791738
15. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 2007;16(6):717-21. https://doi.org/10.1016/j.jse.2007.02.123
16. Mather J, MacDermid JC, Faber KJ, Athwal GS. Proximal humerus cortical bone thickness correlates with bone
mineral density and can clinically rule out osteoporosis. J Shoulder Elbow Surg 2013;22(6):732-8.
https://doi.org/10.1016/j.jse.2012.08.018
17. Assunção JH, Malavolta EA, Beraldo RA, Gracitelli MEC, Bordalo-Rodrigues M, Ferreira Neto AA. Impact of
shoulder rotation on neck-shaft angle: A clinical study. Orthop Traumatol Surg Res 2017;103(6):865-8.
https://doi.org/10.1016/j.otsr.2017.04.007
18. Cha H, Park KB, Oh S, Jeong J. Treatment of comminuted proximal humeral fractures using locking plate with strut allograft. J Shoulder Elbow Surg 2017;26(5):781-5. https://doi.org/10.1016/j.jse.2016.09.055
19. Lee SH, Han SS, Yoo BM, Kim JW. Outcomes of locking plate fixation with fibular allograft augmentation for
proximal humeral fractures in osteoporotic patients. Bone Joint J 2019;101-B(3):260-5.
https://doi.org/10.1302/0301-620X.101B3.BJJ-2018-0802.R1
20. Cui X, Chen H, Ma B, Fan W, Li H. Fibular strut allograft influences reduction and outcomes after locking plate
fixation of comminuted proximal humeral fractures in elderly patients: A retrospective study. BMC Musculoskelet
Disord 2019; 20(1):511. https://doi.org/10.1186/s12891-019-2907-3
21. Matassi F, Angeloni R, Carulli C, Civinini R, Di Bella L, Redl B, et al. Locking plate and fibular allograft
augmentation in unstable fractures of proximal humerus. Injury 2012;43(11):1939-42. https://doi.org/10.1016/j.injury.2012.08.004
22. Hsiao CK, Tsai YJ, Yen CY, Lee CH, Yang TY, Tu YK. Intramedullary cortical bone strut improves the cyclic
stability of osteoporotic proximal humeral fractures. BMC Musculoskelet Disord 2017;18(1):64.
https://doi.org/10.1186/s12891-017-1421-8
23. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 2008;22(3):195-200.
https://doi.org/10.1097/BOT.0b013e31815b3922
24. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications
associated with proximal humeral locking plates. Clin Orthop Relat Res 2011;469(12):3300-6.
https://doi.org/10.1007/s11999-011-1949-0
25. Avilucea FR, Shaath K, Kozlowski R, Rezaieet N. Modified use of a fibular strut in the reduction and stabilization of 2-part osteoporotic proximal humerus fractures. J Am Acad Orthop Surg Glob Res Rev 2020;4(10):e20.00153. https://doi.org/10.5435/JAAOSGlobal-D-20-00153
open reduction and internal fixation of proximal humerus fractures: a systematic review and the authors’ preferred surgical technique. Orthop J Sport Med 2016;4(7):1-9. https://doi.org/10.1177/2325967116656829
2. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006;442:87-92. https://doi.org/10.1097/01.blo.0000194672.79634.78
3. Resch H, Tauber M, Neviaser RJ, Neviaser SN, Majed A, Halsey T, et al. Classification of proximal humeral
fractures based on a pathomorphologic analysis. J Shoulder Elbow Surg 2016;25(3):455-62. https://doi.org/10.1016/j.jse.2015.08.006
4. Gupta AK, Harris JD, Erickson BJ, Abrams GD, Bruce B, McCormick F, et al. Surgical management of complex
proximal humerus fractures - A systematic review of 92 studies including 4500 patients. J Orthop Trauma 2015;
29(1):54-9. https://doi.org/10.1097/BOT.0000000000000229
5. Walsh S, Reindl R, Harvey E, Berry G, Beckman L, Steffen T. Biomechanical comparison of a unique locking
plate versus a standard plate for internal fixation of proximal humerus fractures in a cadaveric model. Clin Biomech (Bristol, Avon) 2006;21(10):1027-31. https://doi.org/10.1016/j.clinbiomech.2006.06.005
6. Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: A prospective multicenter analysis. J Orthop Trauma 2009;23(3):163-72. https://doi.org/10.1097/BOT.0b013e3181920e5b
7. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked
plating of proximal humerus fractures. J Orthop Trauma 2007;21(3):185-91. https://doi.org/10.1097/BOT.0b013e3180333094
8. Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani NC, Zuckerman JD. Early complications in proximal humerus
fractures (OTA types 11) treated with locked plates. J Orthop Trauma 2008;22(3):159-64. https://doi.org/10.1097/BOT.0b013e318169ef2a
9. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the
PHILOS plate: Early experience. Clin Orthop Relat Res 2006;(442):115-20. https://doi.org/10.1097/01.blo.0000194678.87258.6e
10. Ricchetti ET, Warrender WJ, Abboud JA. Use of locking plates in the treatment of proximal humerus fractures. J
Shoulder Elbow Surg 2010;19(2 Suppl):66-75. https://doi.org/10.1016/j.jse.2010.01.001
11. Lee CH, Huang KC, Hsiao CK, Cheng S, Liu YC, Chang CH. Biomechanical comparison of the role of inlay graft
in proximal humerus fracture fixed with conventional plate and locking plate. J Mech Med Biol 2013;13(4):1-8.
https://doi.org/10.1142/S0219519413500553
12. Katthagen JC, Schwarze M, Meyer-Kobbe J, Voigt C, Hurschler C, Lill H. Biomechanical effects of calcar screws
and bone block augmentation on medial support in locked plating of proximal humeral fractures. Clin Biomech
(Bristol, Avon) 2014;29(7):735-41. https://doi.org/10.1016/j.clinbiomech.2014.06.008
13. Tingart MJ, Apreleva M, von Stechow D, Zurakowski D, Warner JJP. The cortical thickness of the proximal humeral diaphysis predicts bone mineral density of the proximal humerus. J Bone Joint Surg Br 2003;85(4):611-7.
https://doi.org/10.1302/0301-620x.85b4.12843
14. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res
1987;(214):160-4. PMID: 3791738
15. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 2007;16(6):717-21. https://doi.org/10.1016/j.jse.2007.02.123
16. Mather J, MacDermid JC, Faber KJ, Athwal GS. Proximal humerus cortical bone thickness correlates with bone
mineral density and can clinically rule out osteoporosis. J Shoulder Elbow Surg 2013;22(6):732-8.
https://doi.org/10.1016/j.jse.2012.08.018
17. Assunção JH, Malavolta EA, Beraldo RA, Gracitelli MEC, Bordalo-Rodrigues M, Ferreira Neto AA. Impact of
shoulder rotation on neck-shaft angle: A clinical study. Orthop Traumatol Surg Res 2017;103(6):865-8.
https://doi.org/10.1016/j.otsr.2017.04.007
18. Cha H, Park KB, Oh S, Jeong J. Treatment of comminuted proximal humeral fractures using locking plate with strut allograft. J Shoulder Elbow Surg 2017;26(5):781-5. https://doi.org/10.1016/j.jse.2016.09.055
19. Lee SH, Han SS, Yoo BM, Kim JW. Outcomes of locking plate fixation with fibular allograft augmentation for
proximal humeral fractures in osteoporotic patients. Bone Joint J 2019;101-B(3):260-5.
https://doi.org/10.1302/0301-620X.101B3.BJJ-2018-0802.R1
20. Cui X, Chen H, Ma B, Fan W, Li H. Fibular strut allograft influences reduction and outcomes after locking plate
fixation of comminuted proximal humeral fractures in elderly patients: A retrospective study. BMC Musculoskelet
Disord 2019; 20(1):511. https://doi.org/10.1186/s12891-019-2907-3
21. Matassi F, Angeloni R, Carulli C, Civinini R, Di Bella L, Redl B, et al. Locking plate and fibular allograft
augmentation in unstable fractures of proximal humerus. Injury 2012;43(11):1939-42. https://doi.org/10.1016/j.injury.2012.08.004
22. Hsiao CK, Tsai YJ, Yen CY, Lee CH, Yang TY, Tu YK. Intramedullary cortical bone strut improves the cyclic
stability of osteoporotic proximal humeral fractures. BMC Musculoskelet Disord 2017;18(1):64.
https://doi.org/10.1186/s12891-017-1421-8
23. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 2008;22(3):195-200.
https://doi.org/10.1097/BOT.0b013e31815b3922
24. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications
associated with proximal humeral locking plates. Clin Orthop Relat Res 2011;469(12):3300-6.
https://doi.org/10.1007/s11999-011-1949-0
25. Avilucea FR, Shaath K, Kozlowski R, Rezaieet N. Modified use of a fibular strut in the reduction and stabilization of 2-part osteoporotic proximal humerus fractures. J Am Acad Orthop Surg Glob Res Rev 2020;4(10):e20.00153. https://doi.org/10.5435/JAAOSGlobal-D-20-00153