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Maturana C, Peterson B, Shi B, Mooney B, Clites T, Kremen TJ. Reverse total shoulder arthroplasty with proximal bone loss: a biomechanical comparison of partially vs. fully cemented humeral stems. J Shoulder Elbow Surg 2024; 33:2039-2047. [PMID: 38417733 PMCID: PMC11330736 DOI: 10.1016/j.jse.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/21/2023] [Accepted: 01/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The appropriate amount of cementation at the time of reverse total shoulder arthroplasty with significant proximal bone loss or resection is unknown. Extensive cementation of a humeral prosthesis makes eventual revision arthroplasty more challenging, increasing the risk of periprosthetic fracture. We analyzed the degree of subsidence and torque tolerance of humeral components undergoing standard cementation technique vs. our reduced polymethyl methacrylate (PMMA) protocol. Reduced cementation may provide sufficient biomechanical stability to resist physiologically relevant loads, while still permitting a clinically attainable torque for debonding the prosthesis. METHODS A total of 12 cadaveric humeri (6 matched pairs) underwent resection of 5 cm of bone distal to the greater tuberosity. Each pair of humeri underwent standard humeral arthroplasty preparation followed by either cementation using a 1.5-cm PMMA sphere at a location 3 cm inferior to the porous coating or standard full stem cementation. A 6-degree-of-freedom robot was used to perform all testing. Each humeral sample underwent 200 cycles of abduction, adduction, and forward elevation while being subjected to a physiologic compression force. Next, the samples were fixed in place and subjected to an increasing torque until implant-cement separation or failure occurred. Paired t tests were used to compare mean implant subsidence vs. a predetermined 5-mm threshold, as well as removal torque in matched samples. RESULTS Fully and partially cemented implants subsided 0.49 mm (95% CI 0.23-0.76 mm) and 1.85 mm (95% CI 0.41-3.29 mm), respectively, which were significantly less than the predetermined 5-mm threshold (P < .001 and P < .01, respectively). Removal torque between fully cemented stems was 45.22 Nm (95% CI 21.86-68.57 Nm), vs. 9.26 Nm (95% CI 2.59-15.93 Nm) for partially cemented samples (P = .021). Every fully cemented humerus fractured during implant removal vs. only 1 in the reduced-cementation group. The mean donor age in our study was 76 years (range, 65-80 years). Only 1 matched pair of humeri belonged to a female donor with comorbid osteoporosis. The fractured humerus in the partially cemented group belonged to that donor. CONCLUSION Partially and fully cemented humeral prostheses had subsidence that was significantly less than 5 mm. Partially cemented stems required less removal torque for debonding of the component from the cement mantle. In all cases, removal of fully cemented stems resulted in humeral fracture. Reduced cementation of humeral prostheses may provide both sufficient biomechanical stability and ease of future component removal.
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Affiliation(s)
- Carlos Maturana
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Brandon Peterson
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Brendan Shi
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Bailey Mooney
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tyler Clites
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas J Kremen
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA.
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Li DY, Zhang K. Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:368. [PMID: 38730497 PMCID: PMC11084043 DOI: 10.1186/s12891-024-07502-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/07/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND This systemic review and meta-analysis aimed to evaluate the clinical outcomes of proximal humeral fracture in elderly patient fixation using locked plate with or without cement augmentation. METHODS The databases of PubMed, Embase, and Cochrane Library were searched in August 2023 for literature comparing the clinical outcomes of patients with PHFs treated with locked plate alone and locked plate augmented with cement. Data describing study design; level of evidence; inclusion criteria; demographic information; final follow-up; revision rate; implant failure rate; avascular necrosis rate; total complication rate; constant score; and disability of arm, shoulder, and hand (DASH) score were collected. RESULTS Eight studies (one randomized-controlled trial and seven observational studies), involving 664 patients, were identified. Compared with locked plates alone, using cement-augmented locked plates reduced the implant failure rate (odds ratio (OR) = 0.19; 95% confidence interval (CI) 0.10-0.39; P < 0.0001) and total complication rate (OR = 0.45; 95% CI 0.29-0.69; P = 0.0002) and improved DASH scores (mean difference (MD) = 2.99; 95% CI 1.00-4.98; P = 0.003). However, there was no significant difference in clinical outcomes, including revision rate, avascular necrosis rate, and constant score. CONCLUSION In this review and meta-analysis, fixation of the PHFs in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. Good results are expected for most patients treated with this technique. TRIAL REGISTRATION The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)21 guidelines were followed to conduct this systematic review and meta-analysis and was registered as a protocol in PROSPERO (CRD42022318798).
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Affiliation(s)
- Dong-Yang Li
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Xi'an, Shaanxi Province, 710054, P.R. China
| | - Kun Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Xi'an, Shaanxi Province, 710054, P.R. China.
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Opperman FLJ, Blaas LS, Pape M, Buijs N, Sterkenburg MV, Yuan JZ, Lameijer CM, Derksen RJ. Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study. JSES Int 2024; 8:21-26. [PMID: 38312278 PMCID: PMC10837717 DOI: 10.1016/j.jseint.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes. Methods In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared. Results Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7). Conclusion Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.
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Affiliation(s)
| | - Leanne S. Blaas
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | - Merel Pape
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | - Nikki Buijs
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | | | - Jian Zhang Yuan
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
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Zhelev D, Hristov S, Zderic I, Ivanov S, Visscher L, Baltov A, Ribagin S, Stoffel K, Kralinger F, Winkler J, Richards RG, Varga P, Gueorguiev B. Treatment of Metaphyseal Defects in Plated Proximal Humerus Fractures with a New Augmentation Technique-A Biomechanical Cadaveric Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1604. [PMID: 37763723 PMCID: PMC10536689 DOI: 10.3390/medicina59091604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Unstable proximal humerus fractures (PHFs) with metaphyseal defects-weakening the osteosynthesis construct-are challenging to treat. A new augmentation technique of plated complex PHFs with metaphyseal defects was recently introduced in the clinical practice. This biomechanical study aimed to analyze the stability of plated unstable PHFs augmented via implementation of this technique versus no augmentation. Materials and Methods: Three-part AO/OTA 11-B1.1 unstable PHFs with metaphyseal defects were created in sixteen paired human cadaveric humeri (average donor age 76 years, range 66-92 years), pairwise assigned to two groups for locked plate fixation with identical implant configuration. In one of the groups, six-milliliter polymethylmethacrylate bone cement with medium viscosity (seven minutes after mixing) was placed manually through the lateral window in the defect of the humerus head after its anatomical reduction to the shaft and prior to the anatomical reduction of the greater tuberosity fragment. All specimens were tested biomechanically in a 25° adduction, applying progressively increasing cyclic loading at 2 Hz until failure. Interfragmentary movements were monitored by motion tracking and X-ray imaging. Results: Initial stiffness was not significantly different between the groups, p = 0.467. Varus deformation of the humerus head fragment, fracture displacement at the medial humerus head aspect, and proximal screw migration and cut-out were significantly smaller in the augmented group after 2000, 4000, 6000, 8000 and 10,000 cycles, p ≤ 0.019. Cycles to 5° varus deformation of the humerus head fragment-set as a clinically relevant failure criterion-and failure load were significantly higher in the augmented group, p = 0.018. Conclusions: From a biomechanical standpoint, augmentation with polymethylmethacrylate bone cement placed in the metaphyseal humerus head defect of plated unstable PHFs considerably enhances fixation stability and can reduce the risk of postoperative complications.
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Affiliation(s)
- Daniel Zhelev
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
- Department of Orthopedics and Traumatology, University Hospital for Active Treatment, 8018 Burgas, Bulgaria;
| | - Stoyan Hristov
- Department of Orthopedics and Traumatology, University Hospital for Active Treatment, 8018 Burgas, Bulgaria;
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Stoyan Ivanov
- Department of Orthopaedics and Traumatology, Medical University of Varna, 9002 Varna, Bulgaria;
| | - Luke Visscher
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
- School of Medicine, Queensland University of Technology, Brisbane 4000, Australia
| | - Asen Baltov
- Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine ‘N. I. Pirogov’, 1606 Sofia, Bulgaria;
| | - Simeon Ribagin
- Department of Health Pharmaceutical Care, Medical College, University ‘Prof. Dr. Asen Zlatarov’, 8010 Burgas, Bulgaria;
| | - Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Franz Kralinger
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria;
- Trauma and Sports Department, Ottakring Clinic, Teaching Hospital, Medical University of Vienna, 1160 Vienna, Austria
| | - Jörg Winkler
- Cantonal Hospital Graubuenden, 7000 Chur, Switzerland;
| | - R. Geoff Richards
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
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Schöbel T, Schleifenbaum S, Nitsch V, Hepp P, Theopold J. Primary stability of cement augmentation in locking plate fixation for proximal humeral fractures: A comparison of absorbable versus non-absorbable cement. Clin Biomech (Bristol, Avon) 2022; 91:105516. [PMID: 34814041 DOI: 10.1016/j.clinbiomech.2021.105516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/25/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cement augmentation has been suggested to increase the stability of screw anchoring in osteoporotic humeral fractures. Initial results are promising but may be jeopardized by cement leakage into the joint and difficult implant removal. Absorbable cement might have advantages in this regard, but it is unclear if the primary stability of both techniques is equivalent to each other. Therefore, this study aimed to compare its primary stability with that of non-absorbable cement augmentation. METHODS Nineteen cadaveric humeri with two-part fracture models were treated with locking plate osteosynthesis and cement augmentation using either absorbable calcium phosphate cement (group 1) or polymethylmethacrylate (group 2). Fracture movement, stiffness, failure mode, and ultimate load under cyclic compressive loading were examined and compared between the groups. FINDINGS The absolute and relative stiffness values in group 1 were significantly smaller than those in group 2 after 50 cycles (group 1: 114 ± 38 N/mm and 94 ± 8% vs. group 2: 188 ± 71 N/mm and 106 ± 9%; p50 = 0.022), 2000 cycles (group 1: 97 ± 34 N/mm and 81 ± 15% vs. group 2: 153 ± 47 N/mm and 88 ± 15%; p2000 = 0.028), and 5000 cycles (group 1: 98 ± 40 N/mm and 81 ± 22% vs. group 2: 158 ± 40 N/mm and 92 ± 16%; p5000 = 0.028). The failure load was not statistically significantly different between the groups. INTERPRETATION Although the PMAA group showed higher values for absolute and relative stiffness, no statistically significant difference was found in the primary stability between absorbable and non-absorbable cement augmentation supporting plate osteosynthesis in proximal humeral fractures. In view of the potential advantages of bio-absorbable cement during the healing process, its use should be considered for the augmentation and stabilization of osteoporotic fractures.
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Affiliation(s)
- Tobias Schöbel
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
| | - Stefan Schleifenbaum
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany; ZESBO - Center for Research on Musculoskeletal Systems, Semmelweisstrasse 14, 04103 Leipzig, Germany; Fraunhofer Institute for Machine Tools and Forming Technology, Nöthnitzer Straße 44, 01187 Dresden, Germany.
| | - Viktoria Nitsch
- ZESBO - Center for Research on Musculoskeletal Systems, Semmelweisstrasse 14, 04103 Leipzig, Germany.
| | - Pierre Hepp
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
| | - Jan Theopold
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
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Siebenbürger G, Fleischhacker E, Stumpf U, Helfen T, Böcker W, Ockert B. Screw-Tip Augmented Locked Plating Versus Primary Reverse Total Shoulder Arthroplasty in Displaced Proximal Humeral Fractures: A Retrospective Comparative Cohort Study With a Mean Follow-Up of 39 Months. Geriatr Orthop Surg Rehabil 2021; 12:21514593211039026. [PMID: 35070475 PMCID: PMC8781273 DOI: 10.1177/21514593211039026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/22/2021] [Accepted: 07/25/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction This study compared the clinical and radiologic outcomes of screw-tip augmented locking plate osteosynthesis (STA) vs primary reverse total shoulder arthroplasty (RSA) in elderly patients with displaced proximal humeral fractures. Methods 60 patients (age >65 years) with a displaced proximal humeral fracture underwent open reduction and internal fixation with locking plate and fluoroscopy controlled screw-tip augmentation. Sixty matched individuals (age, gender, fracture pattern, and mean follow-up) treated by RSA for fractures were identified from the institutional database and outcomes as well as occurring complications and need for revision surgery were compared. Results At 39 months’ follow-up, 25 patients in the STA group (mean age 74.5 ± 12 years, 76.7% woman) showed a mean Constant Score (CS) of 68 ± 18.8 points. Mean %CS compared to the contralateral side was 81.6 ± 19.8%. Of 60 matched individuals in the RSA group, 22 patients (mean age 78.9 ± 8.2 years, 76.7% woman) showed a mean CS of 60.6 ± 21.2 points (P = .33), and the mean %CS compared to the contralateral side was 81.6 (74.7 ± 18.6)% (P = .14). The overall complication rate in STA group was 32% (secondary varus or valgus displacement >10°, n = 4, avascular necrosis, n = 4). In RSA group, the overall complication rate was 4.5% (P = <.05). We observed one early onset infection. Revision surgery with removal of the prosthesis and PMMA spacer implantation for two-stage revision was necessary. The follow-up rate was 41.7 vs 36.7%. Conclusions Screw-tip augmented locked plating and reverse total shoulder arthroplasty result in comparable satisfying functional outcome 3 years following a displaced proximal humeral fracture in elderly patients. However, we noted a higher complication and revision rate in the STA group. In contrast, primary reversed shoulder arthroplasty resulted in a lower rate of complications and revisions, which may be beneficial in elderly patients.
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Affiliation(s)
- Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Evi Fleischhacker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Ulla Stumpf
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Ben Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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RUSPI MARIALUISA, MARRAS DANIELE, CRISTOFOLINI LUCA. DOES CEMENT CURING CAUSE CONCERNING INCREASE OF THE TEMPERATURE WHEN DELIVERED IN THE HUMAN HUMERUS? J MECH MED BIOL 2021. [DOI: 10.1142/s0219519421500603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
For the treatment of humeral fractures, numerous strategies exist to improve the clinical outcome of the reconstruction and to reduce the incidence of fixation failure. Injection of acrylic-based cements to reinforce the bone and/or augment the screws is one option. The heat generated during cement polymerization raises some concerns, as it could cause tissue damage. The first aim of this study was to measure the temperature over time during polymerization when acrylic cements are delivered inside the bone to treat fracture. The second aim was to assess if the ISO-5833:2002 standard can predict what happens in a real bone. Different tests were performed using two acrylic-based cements (Mendec and Cal-Cemex): (i) the ISO-5833:2002 standard (Annex C); (ii) tests on human bones (humeral diaphysis and humeral head) injected with cement to simulate fracture treatment. In the humeri, the highest temperature was measured in the diaphysis (68.6∘C for Mendec, 62.7∘C for Cal-Cemex). These values are comparable with the temperature reached in other consolidated applications (vertebroplasty). Exposure to high temperature was shorter for the diaphysis than for the head. For both cements, in both the diaphysis and the head, temperatures exceeded 48∘C for less than 10[Formula: see text]min. This is within the threshold for tissue necrosis. The ISO-5833:2002 yielded significantly different results in terms of maximum temperature (difference exceeding 15∘C) and exposure to temperature above 48∘C and 45∘C. This discrepancy is probably due to a combination of factors affecting the amount of heat produced and dissipated (e.g., amount and shape of the cement, thermal conductivity).
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Affiliation(s)
- MARIA LUISA RUSPI
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum, University of Bologna, Via Umberto Terracini 24-28, 40131 Bologna, Italy
| | - DANIELE MARRAS
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum, University of Bologna, Via Umberto Terracini 24-28, 40131 Bologna, Italy
| | - LUCA CRISTOFOLINI
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum, University of Bologna, Via Umberto Terracini 24-28, 40131 Bologna, Italy
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Burkhard B, Schopper C, Ciric D, Mischler D, Gueorguiev B, Varga P. Overdrilling increases the risk of screw perforation in locked plating of complex proximal humeral fractures - A biomechanical cadaveric study. J Biomech 2021; 117:110268. [PMID: 33529942 DOI: 10.1016/j.jbiomech.2021.110268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/28/2020] [Accepted: 01/16/2021] [Indexed: 02/06/2023]
Abstract
Locked plating of proximal humerus fractures (PHF) is associated with high failure rates (15-37%). Secondary screw perforation is a prominent mode of failure for PHF and typically requires reoperation. The anatomical fracture reduction is an essential factor to prevent fixation failure. However, recent studies indicate that the risk of secondary screw perforation may increase if the articular surface is perforated during predrilling of the screw boreholes (overdrilling). This study aimed to determine whether overdrilling increases the risk of secondary screw perforation in unstable PHF. Nine pairs of human cadaveric proximal humeri were osteotomized to simulate a malreduced and highly unstable 3-part fracture (AO/OTA 11 B1.1), followed by their assignment to two study groups for overdrilling or accurate predrilling in paired design, and fixation with a locking plate. Overdrilling was defined by drilling the calcar screw's boreholes through the articular surface. All humeri were cyclically loaded to screw perforation failure. Number of cycles to initial screw loosening and final perforation failure were analysed. The accurately predrilled group revealed a significantly higher number of cycles to both initial screw loosening (p < 0.01) and final screw perforation failure (p = 0.02), compared to the overdrilled one. This is the first study reporting that drilling to the correct depth significantly increases endurance until screw perforation failure during cyclic loading after locked plating in a highly unstable PHF model. Prevention of overdrilling the boreholes could help reduce failure rates of locked plating. Future work should investigate the prevalence and consequences of overdrilling in clinics.
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Affiliation(s)
- Benjamin Burkhard
- AO Research Institute Davos, Davos, Switzerland; ETH Zurich, Zurich, Switzerland
| | - Clemens Schopper
- AO Research Institute Davos, Davos, Switzerland; University Hospital Ulm, Ulm, Germany
| | - Daniel Ciric
- AO Research Institute Davos, Davos, Switzerland; Flinders University, Tonesly, Australia
| | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland.
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Cristofolini L, Ruspi ML, Marras D, Cavallo M, Guerra E. Reconstruction of proximal humeral fractures without screws using a reinforced bone substitute. J Biomech 2020; 115:110138. [PMID: 33288210 DOI: 10.1016/j.jbiomech.2020.110138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 11/25/2022]
Abstract
Multi-fragment fractures are still a challenge: current clinical practice relies on plates and screws. Treatment of fractures of the proximal humerus has the intra-operative risk of articular damage when inserting multiple screws. Distal-varus collapse of the head is a frequent complication in osteoporotic patients. The aim of this biomechanical study was to investigate if an Innovative-cement-technique (the screws are replaced by injection of cement) provides the same or better stability of the reconstructed head compared to the Standard-technique (locking screws). A four-fragment fracture was simulated in twelve pairs of humeri, with removal of part of the cancellous bone to simulate osteoporotic "eggshell" defect. One humerus of each pair was repaired either with a Standard-technique (locking plate, 2 cortical and 6 locking screws), or with the Innovative-cement-technique (injection of a partially-resorbable reinforced bone substitute consisting of PMMA additivated with 26% beta-TCP). Cement injection was performed both in the lab and under fluoroscopic monitoring. The reconstructed specimens were tested to failure with a cyclic force of increasing amplitude. The Innovative-cement-technique withstood a force 3.57 times larger than the contralateral Standard reconstructions before failure started. The maximum force before final collapse for the Innovative-cement-technique was 3.56 times larger than the contralateral Standard-technique. These differences were statistically significant. The Innovative-cement-technique, based on the reinforced bone substitute, demonstrated better biomechanical properties compared to the Standard-technique. These findings, along with the advantage of avoiding the possible complications associated with the locking screws, may help safer and more effective treatment in case of osteoporotic multi-fragment humeral fractures.
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Affiliation(s)
- Luca Cristofolini
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Bologna, Italy.
| | - Maria Luisa Ruspi
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Daniele Marras
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum - Università di Bologna, Bologna, Italy
| | - Marco Cavallo
- Shoulder and Elbow Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Enrico Guerra
- Shoulder and Elbow Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Varga P, Inzana JA, Fletcher JWA, Hofmann-Fliri L, Runer A, Südkamp NP, Windolf M. Cement augmentation of calcar screws may provide the greatest reduction in predicted screw cut-out risk for proximal humerus plating based on validated parametric computational modelling: Augmenting proximal humerus fracture plating. Bone Joint Res 2020; 9:534-542. [PMID: 32922762 PMCID: PMC7469511 DOI: 10.1302/2046-3758.99.bjr-2020-0053.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aims Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement. Conclusion The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation.
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Affiliation(s)
- Peter Varga
- AO Research Institute Davos, Davos, Graubünden, Switzerland
| | - Jason A Inzana
- AO Research Institute Davos, Davos, Graubünden, Switzerland.,Telos Partners, LLC, Denver, Colorado, USA
| | - James W A Fletcher
- AO Research Institute Davos, Davos, Graubünden, Switzerland.,Department for Health, University of Bath, Bath, UK
| | | | - Armin Runer
- Medical University Innsbruck, Innsbruck, Tirol, Austria
| | - Norbert P Südkamp
- Department of Orthopaedics and Trauma Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Markus Windolf
- AO Research Institute Davos, Davos, Graubünden, Switzerland
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11
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Cristofolini L, Morellato K, Cavallo M, Guerra E. Reconstruction of proximal humeral fractures with a reduced number of screws and a reinforced bone substitute. Med Eng Phys 2020; 82:97-103. [DOI: 10.1016/j.medengphy.2020.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 02/04/2023]
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12
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Synthetic Bone Substitutes and Mechanical Devices for the Augmentation of Osteoporotic Proximal Humeral Fractures: A Systematic Review of Clinical Studies. J Funct Biomater 2020; 11:jfb11020029. [PMID: 32380687 PMCID: PMC7353588 DOI: 10.3390/jfb11020029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Different augmentation techniques have been described in the literature in addition to the surgical treatment of proximal humeral fractures. The aim of this systematic review was to analyze the use of cements, bone substitutes, and other devices for the augmentation of proximal humeral fractures. METHODS A systematic review was conducted by using PubMed/MEDLINE, ISI Web of Knowledge, Cochrane Library, Scopus/EMBASE, and Google Scholar databases according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines over the years 1966 to 2019. The search term "humeral fracture proximal" was combined with "augmentation"; "polymethylmethacrylate, PMMA"; "cement"; "bone substitutes"; "hydroxyapatite"; "calcium phosphates"; "calcium sulfate"; "cell therapies", and "tissue engineering" to find the literature relevant to the topic under review. RESULTS A total of 10 clinical studies considered eligible for the review, with a total of 308 patients, were included. Mean age at the time of injury was 68.8 years (range of 58-92). The most commonly described techniques were reinforcing the screw-bone interface with bone PMMA cement (three studies), filling the metaphyseal void with synthetic bone substitutes (five studies), and enhancing structural support with metallic devices (two studies). CONCLUSION PMMA cementation could improve screw-tip fixation. Calcium phosphate and calcium sulfate injectable composites provided good biocompatibility, osteoconductivity, and lower mechanical failure rate when compared to non-augmented fractures. Mechanical devices currently have a limited role. However, the available evidence is provided mainly by level III to IV studies, and none of the proposed techniques have been sufficiently studied.
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13
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Criado A, Yokhana S, Rahman T, McCarty S, Andrecovich C, Ren W, Yassir WK. Biomechanical strength comparison of pedicle screw augmentation using poly-dicalcium phosphate dihydrate (P-DCPD) and polymethylmethacrylate (PMMA) cements. Spine Deform 2020; 8:165-170. [PMID: 32030639 DOI: 10.1007/s43390-019-00022-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 08/25/2019] [Indexed: 12/01/2022]
Abstract
STUDY DESIGN A basic science, hypothesis-driven experimental study of the biomechanics of two bone cements in their ability to augment pedicle screws in bone foam. OBJECTIVE The purpose of our study was to compare the pullout and torque resistance of conventional pedicle screws (CPS) augmented with either polymethylmethacrylate (PMMA) or poly-dicalcium phosphate dihydrate (P-DCPD) cement in polyurethane foam blocks mimicking osteoporotic bone. P-DCPD cement has attractive safety characteristics such as non-exothermic curing and drug-eluting capacity. PMMA cement lacks these safety features yet is the current standard in pedicle screw augmentation. METHODS Standardized low-density polyurethane open-cell foam blocks were instrumented with conventional pedicle screws and categorized into three groups of six each. Group 1 was the control group and no cement was used. Groups 2 and 3 were augmented with PMMA and P-DCPD, respectively. An Instron machine applied an axial load to failure at a rate of 2 mm/min for 3 min and a torsional load to failure at a rate of 1°/s. Failure was defined by an evident drop in the load after maximum value. RESULTS Maximal pullout load for PMMA and P-DCPD was significantly greater than control (p < 0.0001). Interestingly, there was no significant difference in the pullout load to failure for the PMMA and P-DCPD groups. Analysis showed significant difference in torsional resistance between PMMA and P-DCPD, with PMMA having greater resistance (p = 0.00436). CONCLUSIONS No difference was observed between PMMA and P-DCPD in pullout load to failure conducted in low-density open-cell, rigid foam blocks. Although a significant difference did exist in our torque analysis, the clinical significance of such a load on a native spine is questionable. Further investigation is warranted for this promising compound that seems to be comparable in pullout resistance to PMMA and offers attractive safety features. LEVEL OF EVIDENCE Basic science, not applicable.
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Affiliation(s)
- Alberto Criado
- Department of Orthopedic Surgery, Detroit Medical Center, 4201 St Antoine St, Detroit, MI, 48201, USA
| | - Sanar Yokhana
- Department of Orthopedic Surgery, Detroit Medical Center, 4201 St Antoine St, Detroit, MI, 48201, USA
| | - Tahsin Rahman
- Wayne State University School of Medicine, 7733 Woodward Ave, Detroit, MI, 48202, USA.
| | - Scott McCarty
- Department of Orthopedic Surgery, Detroit Medical Center, 4201 St Antoine St, Detroit, MI, 48201, USA
| | - Christopher Andrecovich
- Department of Biomedical Engineering, Wayne State University, 818 W Hancock St, Detroit, MI, 48201, USA
| | - Weiping Ren
- Department of Biomedical Engineering, Wayne State University, 818 W Hancock St, Detroit, MI, 48201, USA
| | - Walid Khaled Yassir
- Department of Orthopedic Surgery, Detroit Medical Center, 4201 St Antoine St, Detroit, MI, 48201, USA
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14
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Ciric D, Mischler D, Qawasmi F, Wenzel L, Richards RG, Gueorguiev B, Windolf M, Varga P. Secondary Perforation Risk in Plate Osteosynthesis of Unstable Proximal Humerus Fractures: A Biomechanical Investigation of the Effect of Screw Length. J Orthop Res 2019; 37:2625-2633. [PMID: 31350928 DOI: 10.1002/jor.24429] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/24/2019] [Indexed: 02/04/2023]
Abstract
Secondary perforation of screws into the joint surface is a commonly reported mechanical fixation failure mode in locked plating of proximal humerus fractures (PHF). This study investigated the influence that screws tip to joint distance (TJD) has on the biomechanical risk of secondary screw perforation and the stability of PHF. Ten pairs of cadaveric proximal humeri with a wide range of bone mineral density were used. Each specimen was osteotomized and instrumented with the PHILOS plate, simulating a highly unstable 3-part fracture. Bones were randomized into a long screw group (LSG) with 4 mm TJD, or a short screw group (SSG) with 8 mm TJD. A custom biomechanical setup was used to test the samples to failure cyclically with a constant valley load and an increasing ramp. The number of cycles to the initial screw loosening event was significantly higher for the LSG (mean ± standard deviation: 17,532 ± 6,458) compared with the SSG (11,102 ± 5,440) (p < 0.01). The mode of failure during testing was lateral-inferior displacement combined with varus collapse, with calcar screws perforating first. The number of cycles to failure event for LSG (27,849 ± 5,648) was not significantly different compared with SSG (28,782 ± 7,307) (p = 0.50). Screws that purchase closer to the joint had better initial stability and resistance against loosening. Placing longer screws, within limits dictated by the surgical guide, is expected to decrease the risk of secondary perforation failures in unstable PHF. These findings require clinical corroboration. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2625-2633, 2019.
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Affiliation(s)
- Daniel Ciric
- AO Research Institute Davos, Davos, Switzerland.,College of Science and Engineering, Flinders University, Tonesly, South Australia
| | | | - Feras Qawasmi
- AO Research Institute Davos, Davos, Switzerland.,Hadassah Medical Centre, Jerusalem, Israel
| | - Lisa Wenzel
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma Surgery, Trauma Center Murnau, Murnau, Germany
| | | | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
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15
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Abstract
Despite advances in technology such as locked plating, osteoporotic bone and bone defects remain challenging complications for orthopaedic surgeons. The concept of augmented fixation is useful in these settings. Augmented fixation can be described as improving construct strength and stability by enhancing the surrounding environment. By understanding and using the techniques of alternative fixation strategies, endosteal or medullary support, structural grafting, or the use of bone graft substitutes in combination with standard or integrated fixation, surgeons can improve the chances of success when treating difficult fractures. The purpose of this article is to introduce the reader to the concept of augmented fixation, review strategies for its application, and review applicable published results.
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16
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Elliott R, Regazzola G, Bruce WJM. Ambient theatre temperature and cement setting time in total knee arthroplasty. ANZ J Surg 2019; 89:1424-1427. [PMID: 31628729 DOI: 10.1111/ans.15463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Polymethylmethacrylate cement is used in total knee arthroplasty and plays a significant role in the success of the procedure. Temperature variation is known to influence cement setting time in vitro. Our aim is to evaluate the relationship between ambient theatre temperature and cement setting time in vivo. METHODS Theatre temperature and cement setting time were prospectively recorded during 683 total knee arthroplasties over 8 years using a single cement and vacuum mixing system (Simplex with tobramycin). Setting time was defined as the time until a scalpel blade could not indent the cement surface. RESULTS Mean temperature was 18.92°C (SD 1.16) and setting time 13.08 min (SD 1.92). A moderate inverse relationship exists between ambient temperature and setting time (Pearson's R = -0.423); however, potential setting times within a given temperature range varied considerably (<19°C: 8-19.1 min, 19-20°C: 7-18 min and >20°C: 7.5-16 min), suggesting that temperature alone cannot reliably predict setting time. CONCLUSION Our data support the current understanding of bone cement properties in vivo and suggest that surgeons should be mindful in regards to unpredictable cement setting time and optimal theatre environment.
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Affiliation(s)
- Ross Elliott
- Inner West Hip & Knee Clinic, Concord Hospital, The University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Gianmarco Regazzola
- Inner West Hip & Knee Clinic, Concord Hospital, The University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Warwick J M Bruce
- Inner West Hip & Knee Clinic, Concord Hospital, The University of Sydney Medical School, Sydney, New South Wales, Australia
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17
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Siebenbürger G, Helfen T, Biermann N, Haasters F, Böcker W, Ockert B. Screw-tip augmentation versus standard locked plating of displaced proximal humeral fractures: a retrospective comparative cohort study. J Shoulder Elbow Surg 2019; 28:1326-1333. [PMID: 31056395 DOI: 10.1016/j.jse.2018.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/07/2018] [Accepted: 12/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study compared the clinical and radiologic outcomes of screw tip-augmented locking plate osteosynthesis vs. standard locked plating in elderly patients with displaced proximal humeral fractures. METHODS Of the 94 patients older than 65 years with displaced proximal humeral fractures, 55 underwent fixation with a locking plate only whereas 39 underwent fixation using a locking plate with fluoroscopy-controlled polymethyl methacrylate augmentation of screw tips. RESULTS At 2 years' follow-up, the locking plate-only group showed a mean Constant score (CS) of 62.6 ± 17.4 points, mean CS as a percentage of the uninjured side of 78.2% ± 18.9%, and mean age- and sex-adjusted CS of 72.4 ± 20.5 points. Among the 39 patients who underwent locked plating with polymethyl methacrylate augmentation of screw tips, the mean CS was 63.7 ± 18.5 points (P = .28), the mean CS as a percentage of the uninjured side was 79.5% ± 20.4% (P = .36), and the mean age- and sex-adjusted CS was 76.8 ± 26.2 points (P = .11). The mean Disabilities of the Arm, Shoulder and Hand score was 26.4 ± 21.3 in the locking plate-only group compared with 23.6 ± 19.2 in the group with screw tip-augmented locking plate osteosynthesis (P = .41). The overall complication rate was 16.3% in the locking plate-only group compared with 12.8% in the group with screw tip-augmented osteosynthesis (P = .86); loss of fixation occurred in 10.9% vs. 5.1% (P = .74). The follow-up rate was 81%. CONCLUSIONS Loss of fixation was less frequent when augmentation of screw tips was performed; however, at the 2-year follow-up, the clinical and radiologic outcomes were not significantly different compared with standard locked plating without augmentation.
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Affiliation(s)
- Georg Siebenbürger
- Shoulder and Elbow Service, Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals, Ludwig-Maximilians-University, Munich, Germany
| | - Tobias Helfen
- Shoulder and Elbow Service, Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals, Ludwig-Maximilians-University, Munich, Germany
| | - Niklas Biermann
- Shoulder and Elbow Service, Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals, Ludwig-Maximilians-University, Munich, Germany
| | - Florian Haasters
- Department of Knee, Hip and Shoulder Surgery, Schön Klinik München Harlaching, Munich, Germany
| | - Wolfgang Böcker
- Shoulder and Elbow Service, Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals, Ludwig-Maximilians-University, Munich, Germany
| | - Ben Ockert
- Shoulder and Elbow Service, Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals, Ludwig-Maximilians-University, Munich, Germany.
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18
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Katthagen JC, Dey Hazra RO, Raschke MJ, Heilmann L, Michel P, Lill H, Schliemann B. Innovationen bei der Behandlung der proximalen Humerusfraktur. ARTHROSKOPIE 2018. [DOI: 10.1007/s00142-018-0243-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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19
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Kuang GM, Wong TM, Wu J, Ouyang J, Guo H, Zhou Y, Fang C, Leung FKL, Lu W. Augmentation of a Locking Plate System Using Bioactive Bone Cement-Experiment in a Proximal Humeral Fracture Model. Geriatr Orthop Surg Rehabil 2018; 9:2151459318795312. [PMID: 30305979 PMCID: PMC6176529 DOI: 10.1177/2151459318795312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/10/2018] [Accepted: 07/21/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction: The purpose of this study was to test whether local filling of a novel
strontium-containing hydroxyapatite (Sr-HA) bone cement can augment the fixation of a
locking plate system in a cadaveric proximal humeral facture model. Materials and Methods: Twelve pairs of formalin-treated cadaveric humeri were used. One side in each pair was
for cemented group, while the other side was for the control group. The bone mineral
density (BMD) of the samples was tested. A 3-part facture model was created and then
reduced and fixed by a locking plate system. In the cemented group, the most proximal 4
screw holes were filled with 0.5 mL bone cement. In the control group, the screw holes
were not filled by cement. Locking screws were inserted in a standard manner before the
cement hardened. X-ray was taken before all the specimens being subjected to mechanical
study, in which 6 pairs were used for axial loading (varus bending) test, while other 6
pairs were used for axial rotational test. Results: There is no difference in BMD between the cemented side and the control side. The X-ray
shows that the implant is in position. Cement filling was noted in the most proximal 4
screws in the cemented group. Better mechanical outcome was seen in the cemented groups,
in terms of less maximal displacement per cycle and higher failure point and stiffness
in varus bending test. However, no difference was found between the
cemented group and the control group in the axial rotation test. Discussion: In similarity with the previous studies, our results showed better mechanical results
in the cemented group. However, due to the limitations (e.g. sample size, fracture
model, testing protocol, etc), we still cannot directly extrapolate current mechanical
results to clinical practice at the present moment. Furthermore, it is still unknown
whether better primary outcome may lead to better long-term results, even though the
local release of strontium may enhance the local bone formation. Conclusion: The local filling of Sr-HA bone cement augments the fixation of the locking plate
system in current proximal humeral fracture model.
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Affiliation(s)
- Guan-Ming Kuang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak Man Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Jun Wu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jun Ouyang
- Department of Anatomy and Medical Biomechanical Key Laboratory of Guangdong Province, Southern Medical University, Guangzhou, China
| | - Haihua Guo
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yapeng Zhou
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Frankie K L Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - William Lu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China
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20
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[Traumatology in the elderly : Multimodal prevention of delirium and use of augmentation techniques]. Chirurg 2018; 88:95-104. [PMID: 28058496 DOI: 10.1007/s00104-016-0339-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recent data show that 20-80% of surgery patients are affected by delirium during inpatient clinical treatment. The medical consequences are often dramatic and include a 20 times higher mortality and treatment expenses of the medical unit increase considerably. At the University Hospital of Münster a multimodal and interdisciplinary concept for prevention and management of delirium was developed: all patients older than 65 years admitted for surgery are screened by a specialized team for the risk of developing delirium and treated by members of the team if there is a risk of delirium. Studies proved that by this multimodal approach the incidence of delirium was lowered and therefore the quality of medical care improved.When surgical treatment of fractures in the elderly is required, limited bone quality as well as pre-existing implants can complicate the procedure. Secondary loss of reduction after osteosynthesis and avulsion of the implant in particular must be prevented. Augmentation of the osteosynthetic implant with bone cement can increase the bone-implant interface and therefore stability can be improved. Additional intraoperative 3D imaging can be necessary depending on the localization of the fracture. In biomechanical studies we could prove greater stability in the osteosynthesis of osteoporotic fractures of the distal femur when using additional bone cement; therefore, the use of bone cement is an important tool, which helps to prevent complications in the surgical treatment of fractures in the elderly. Nevertheless, special implants and technical skills are required and some safety aspects should be considered.
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21
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Katthagen JC, Lutz O, Voigt C, Lill H, Ellwein A. Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures. ACTA ACUST UNITED AC 2018; 13:123-129. [PMID: 29887918 PMCID: PMC5976700 DOI: 10.1007/s11678-018-0440-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/05/2018] [Indexed: 11/09/2022]
Abstract
Background Cement augmentation (CA) of humeral head screws in locked plating of proximal humeral fractures (PHF) was found to be biomechanically beneficial. However, clinical outcomes of this treatment have not been well evaluated to date. Objectives To assess outcomes of locked plating of PHF with additional CA and to compare them with outcomes of conventional locked plating without CA. Methods 24 patients (mean age, 74.2 ± 10.1 years; 22 female) with displaced PHF were prospectively enrolled and treated with locked plating and additional CA. The Constant score (CS), the Simple Shoulder Test (SST), and the Simple Shoulder Value (SSV) were assessed 3 and 12 months postoperatively. Fracture healing and potential complications were evaluated on postoperative radiographs. The CS and complications were compared with the outcomes of a matched group of 24 patients (mean age, 73.9 ± 9.4 years; 22 female) with locked plating of displaced PHF without CA. Results At the 3‑month follow-up, the mean CS was 59.9 ± 15.6 points, the mean SST was 7.5 ± 2.7 points, and the mean SSV was 63.9 ± 21.7%. All scores significantly improved by the 12-month follow-up (p < 0.05; CS, 72.9 ± 17.7; SST, 9.2 ± 3.2; SSV, 77.2 ± 17.3%). There were two cases (8%) of biological complications (n = 1 varus malunion and n = 1 humeral head necrosis). Compared with locked plating without CA, no significant differences were observed between the CS at the 3‑ (57.8 ± 13.4 points; p = 0.62) and 12-month (73.0 ± 12.8 points; p = 0.99) follow-up. However, patients without CA had a significantly increased risk of early loss of reduction and articular screw perforation (p = 0.037). Conclusion Locked plating of proximal humeral fractures with trauma cement augmentation of humeral head screws could be translated from the ex-vivo lab setting into the clinical situation without additional complications. Locked plating of displaced PHF with additional cement augmentation showed similar clinical outcomes but reduced the rate of early implant-related complications compared to locked plating without additional CA.
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Affiliation(s)
- J Christoph Katthagen
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany.,2Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Str. 1, 48149 Münster, Germany
| | - O Lutz
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
| | - C Voigt
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
| | - H Lill
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
| | - A Ellwein
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
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22
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Shi BY, Diaz M, Belkoff SM, Srikumaran U. Pullout strength of cement-augmented and wide-suture transosseous fixation in the greater tuberosity. Clin Biomech (Bristol, Avon) 2017; 50:154-159. [PMID: 29127887 DOI: 10.1016/j.clinbiomech.2017.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/19/2017] [Accepted: 10/30/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obtaining strong fixation in low-density bone is increasingly critical in surgical repair of rotator cuff tears because of the aging population. To evaluate two new methods of improving pullout strength of transosseous rotator cuff repair in low-density bone, we analyzed the effects of 1) using 2-mm suture tape instead of no. 2 suture and 2) augmenting the lateral tunnel with cement. METHODS Eleven pairs of osteopenic or osteoporotic cadaveric humeri were identified by dual-energy x-ray absorptiometry. One bone tunnel and one suture were placed in the heads of 22 specimens. Five randomly selected pairs were repaired with no. 2 suture; the other six pairs were repaired with 2-mm suture tape. One side of each pair received lateral tunnel cement augmentation. Specimens were tested to suture pullout. Data were fitted to multivariate models that accounted for bone mineral density and other specimen characteristics. FINDINGS Two specimens were excluded because of knot-slipping during testing. Use of suture tape versus no. 2 suture conferred a 75-N increase (95% CI: 37, 113) in pullout strength (P<0.001). Cement augmentation conferred a 42-N improvement (95% CI: 10, 75; P=0.011). Other significant predictors of pullout strength were age, sex, and bone mineral density. INTERPRETATION We show two methods of improving the fixation strength of transosseous rotator cuff repairs in low-density bone: using 2-mm suture tape instead of no. 2 suture and augmenting the lateral tunnel with cement. These methods may improve the feasibility of transosseous repairs in an aging patient population.
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Affiliation(s)
- Brendan Y Shi
- The Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205, United States
| | - Miguel Diaz
- The Johns Hopkins University School of Medicine, 733 North Broadway, Baltimore, MD 21205, United States
| | - Stephen M Belkoff
- Department of Orthopaedic Surgery, The Johns Hopkins University, Johns Hopkins Bayview Medical Center, 5210 Eastern Avenue, Baltimore, MD 21224, United States
| | - Uma Srikumaran
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, United States.
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23
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Fatigue failure of plated osteoporotic proximal humerus fractures is predicted by the strain around the proximal screws. J Mech Behav Biomed Mater 2017; 75:68-74. [DOI: 10.1016/j.jmbbm.2017.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/19/2017] [Accepted: 07/03/2017] [Indexed: 01/20/2023]
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24
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Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res 2017; 12:137. [PMID: 28946902 PMCID: PMC5613450 DOI: 10.1186/s13018-017-0639-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.
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Affiliation(s)
- Christoph J Laux
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Florian Grubhofer
- Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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25
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Abstract
BACKGROUND The rising incidence of osteoporotic fractures requires novel treatment strategies. OBJECTIVE Implant augmentation with bone cement is considered to be a promising approach but the benefits and risks need to be carefully evaluated. METHODS Experimental investigation of the biomechanical potential and the associated risks with special reference to the osteoporotic proximal femur and proximal humerus. RESULTS Even small amounts of bone cement (3 ml) applied to the proximal femur in combination with intramedullary nailing led to more than a 50% increase in the number of test cycles before failure. The heat and pressure generated in the bone did not exceed critical thresholds. Short to midterm effects of subchondral cement placement on the adjacent cartilage can be excluded. The risk for cement leakage needs to be considered. CONCLUSION Implant augmentation offers high biomechanical potential to prevent mechanical complications after fracture fixation in osteoporotic bone. Early and confident mobilization of elderly patients therefore appears to be possible. With appropriate handling, associated risks seem controllable; however, implant augmentation cannot be applied as a routine concept for osteoporotic fracture management. The application requires careful evaluation on a case by case basis under comprehensive consideration of mechanical and biological factors.
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Affiliation(s)
- M Windolf
- AO Forschungsinstitut Davos, Clavadelerstrasse 8, 7270, Davos, Schweiz,
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26
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Bliemel C, Oberkircher L, Bockmann B, Petzold E, Aigner R, Heyse TJ, Ruchholtz S, Buecking B. Impact of cement-augmented condylar screws in locking plate osteosynthesis for distal femoral fractures - A biomechanical analysis. Injury 2016; 47:2688-2693. [PMID: 27773369 DOI: 10.1016/j.injury.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/16/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Compromised bone quality and the need for early mobilization continue to lead to implant failure in elderly patients with distal femoral fractures. The cement augmentation of screws might facilitate improving implant anchorage. The aim of this study was to analyse the impact of cement augmentation of the condylar screws on implant fixation in a human cadaveric bone model. MATERIAL AND METHODS Ten pairs of osteoporotic femora (mean age: 90 years, range: 84-99 years) were used. A 2-cm gap osteotomy was created in the metaphyseal region to simulate an unstable AO/OTA 33-A3 fracture. All specimens were treated with a polyaxial locking plate. Specimens randomly assigned to the augmented group received an additional cement augmentation of the condylar screws using bone cement. A servohydraulic testing machine was used to perform incremental cyclic axial loading using a load-to-failure mode. RESULTS All specimens survived at least 800N of axial compressive force. The mean compressive forces leading to failure were 1620N (95% CI: 1382-1858N) in the non-augmented group and 2420N (95% CI: 2054-2786N) in the group with cement-augmented condylar screws (p=0.005). Deformation with cutting out of the condylar screws and condylar fracture were the most common reasons for failure in both groups. Whereas axial stiffness was comparable between both osteosyntheses (p=0.508), significant differences were observed for the plastic deformation of the constructs (p=0.014). CONCLUSION The results of the present study showed that the cement augmentation of the condylar screws might be a promising technique for the fixation of distal femoral fractures in elderly patients with osteoporotic bones.
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Affiliation(s)
- Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Benjamin Bockmann
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Eric Petzold
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Rene Aigner
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Thomas Jan Heyse
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - Benjamin Buecking
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
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27
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Abstract
There are an increasing number of fragility fractures, which present a surgical challenge given the reduced bone quality of underlying osteoporosis. Particularly in aged patients, there is a need for early weight bearing and mobilization to avoid further complications such as loss of function or autonomy. As an attempt to improve fracture stability and ultimate healing, the use of biomaterials for augmentation of osseous voids and fracture fixation is a promising treatment option. Augmentation techniques can be applied in various locations, and fractures of the metaphyseal regions such as proximal humerus, femur, tibia and the distal radius remain the most common areas for its use. The current review, based on the available mechanical and biological data, provides an overview of the relevant treatment options and different composites used for augmentation of osteoporotic fractures.
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28
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Grüneweller N, Wähnert D, Raschke MJ, Fuchs T. [Implant augmentation in pelvic surgery. Options and technique]. Unfallchirurg 2015; 118:831-7. [PMID: 26341619 DOI: 10.1007/s00113-015-0058-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Osteoporotic fractures of the pelvis are an increasing problem in trauma surgery. Sufficient implant anchorage is reduced due to the poor bone stock; however, early mobilization is especially necessary for geriatric patients in order to prevent additional complications. MATERIAL AND METHODS Implant augmentation may be one technique to increase implant anchorage and stability in osteoporotic bone. This procedure is currently used in the treatment of osteoporotic fractures of the dorsal pelvic ring. Beside the augmentation of iliosacral screws in the treatment of sacral insufficiency fractures, cement augmentation with lumbar or sacral pedicle screws is used for increased stability. INDICATIONS AND RISKS Implant augmentation in pelvic surgery should be indicated crucially due to the specific risks of the procedure. Cement leakage and heat generation during cement curing (when PMMA--polymethylmetacrylate--cement is used) can compromise neurovascular structures. Potential complications like cement embolism are possible. CONCLUSION The use of special implants (cannulated and perforated screws) as well as intraoperative navigation and 3D imaging increase patient safety and help to make implant augmentation a low risk procedure.
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Affiliation(s)
- N Grüneweller
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - D Wähnert
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - M J Raschke
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland.
| | - T Fuchs
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
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29
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How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. Injury 2015; 46:1207-14. [PMID: 25978864 DOI: 10.1016/j.injury.2015.04.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/24/2015] [Accepted: 04/13/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The complication rate after locking plate fixation of proximal humerus fractures is high. In addition to low bone mineral density, a lack of medial support has been identified as one of the most important factors accounting for mechanical instability. As a result of the high failure rate, different strategies have been developed to enhance the mechanical stability of locking plate fixation of proximal humerus fractures. The aim of the present article is to give an overview of the current biomechanical and clinical studies that focus on how to increase the stability of locking plate fixation of proximal humerus fractures. METHODS A comprehensive search of the Medline databases using specific search terms with regard to the stability of locking plate fixation of proximal humerus fractures was performed. After screening of the articles for eligibility, they were subdivided according to clinical and biomechanical aspects. RESULTS Medial support screws, filling of bone voids and screw-tip augmentation with bone cement as well as the application of bone grafts are currently the most frequently assessed and performed methods. Although the evidence is weak, all of the mentioned strategies appear to have a positive effect on achieving and maintaining a stable reduction even of complex fractures. CONCLUSION Further clinical studies with a higher number of patients and a higher level of evidence are required to develop a standardised treatment algorithm with regard to cement augmentation and bone grafting. Although these measures are likely to have a stabilising effect on locking plate fixation, its general use cannot be fully recommended yet.
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30
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Lv Y, Li A, Zhou F, Pan X, Liang F, Qu X, Qiu D, Yang Z. A Novel Composite PMMA-based Bone Cement with Reduced Potential for Thermal Necrosis. ACS APPLIED MATERIALS & INTERFACES 2015; 7:11280-11285. [PMID: 25966790 DOI: 10.1021/acsami.5b01447] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) are now widely used to treat patients who suffer painful vertebral compression fractures. In each of these treatments, a bone cement paste is injected into the fractured vertebral body/bodies, and the cement of choice is a poly(methyl methacrylate) (PMMA) bone cement. One drawback of this cement is the very high exothermic temperature, which, it has been suggested, causes thermal necrosis of surrounding tissue. In the present work, we prepared novel composite PMMA bone cement where microcapsules containing a phase change material (paraffin) (PCMc) were mixed with the powder of the cement. A PCM absorbs generated heat and, as such, its presence in the cement may lead to reduction in thermal necrosis. We determined a number of properties of the composite cement. Compared to the values for a control cement (a commercially available PMMA cement used in VP and BKP), each composite cement was found to have significantly lower maximum exothermic temperature, increased setting time, significantly lower compressive strength, significantly lower compressive modulus, comparable biocompatibility, and significantly smaller thermal necrosis zone. Composite cement containing 20% PCMc may be suitable for use in VP and BKP and thus deserves further evaluation.
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Affiliation(s)
- Yang Lv
- †Orthopedic Department, Peking University Third Hospital, Beijing 100191, China
| | - Ailing Li
- ‡Beijing National Laboratory for Molecular Sciences, State Key Laboratory of Polymer Physics and Chemistry, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, China
| | - Fang Zhou
- †Orthopedic Department, Peking University Third Hospital, Beijing 100191, China
| | - Xiaoyu Pan
- §Medical College of Soochow University, Suzhou 215123, China
| | - Fuxin Liang
- ‡Beijing National Laboratory for Molecular Sciences, State Key Laboratory of Polymer Physics and Chemistry, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, China
| | - Xiaozhong Qu
- ∥University of Chinese Academy of Sciences, Beijing 100190, China
| | - Dong Qiu
- ‡Beijing National Laboratory for Molecular Sciences, State Key Laboratory of Polymer Physics and Chemistry, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, China
| | - Zhenzhong Yang
- ‡Beijing National Laboratory for Molecular Sciences, State Key Laboratory of Polymer Physics and Chemistry, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, China
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31
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Goetzen M, Hofmann-Fliri L, Arens D, Zeiter S, Stadelmann V, Nehrbass D, Richards RG, Blauth M. Does metaphyseal cement augmentation in fracture management influence the adjacent subchondral bone and joint cartilage?: an in vivo study in sheep stifle joints. Medicine (Baltimore) 2015; 94:e414. [PMID: 25621690 PMCID: PMC4602635 DOI: 10.1097/md.0000000000000414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Augmentation of implants with polymethylmethacrylate (PMMA) bone cement in osteoporotic fractures is a promising approach to increase implant purchase. Side effects of PMMA for the metaphyseal bone, particularly for the adjacent subchondral bone plate and joint cartilage, have not yet been studied. The following experimental study investigates whether subchondral PMMA injection compromises the homeostasis of the subchondral bone and/or the joint cartilage.Ten mature sheep were used to simulate subchondral PMMA injection. Follow-ups of 2 (4 animals) and 4 (6 animals) months were chosen to investigate possible cartilage damage and subchondral plate alterations in the knee. Evaluation was completed by means of high-resolution peripheral quantitative computed tomography (HRpQCT) imaging, histopathological osteoarthritis scoring, and determination of glycosaminoglycan content in the joint cartilage. Results were compared with the untreated contralateral knee and statistically analyzed using nonparametric tests.Evaluation of the histological osteoarthritis score revealed no obvious cartilage damage for the treated knee; median histological score after 2 months 0 (range 4), after 4 months 1 (range 5). There was no significant difference when compared with the untreated control site after 2 and 4 months (P = 0.23 and 0.76, respectively). HRpQCT imaging showed no damage to the metaphyseal trabeculae. Glycosaminoglycan measurements of the treated joint cartilage after 4 months revealed no significant difference compared with the untreated cartilage (P = 0.24).The findings of this study support initial clinical observation that PMMA implant augmentation of metaphyseal fractures appears to be a safe procedure for fixation without harming the subchondral bone plate and adjacent joint cartilage.
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Affiliation(s)
- Michael Goetzen
- From the AO Research Institute Davos (MG, L-HF, DA, SZ, VS, DN, GR), Davos, Switzerland; and Department of Trauma Surgery (MG, MB), Medical University of Innsbruck, Innsbruck, Austria
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