Biomechanical evaluation of hybrid double plate osteosynthesis using a locking plate and an inverted third tubular plate for the treatment of proximal humeral fractures

[Proximal humerus fracture: old and new, established and doubtful, conservative and operative aspects]

Proximal humeral fractures are not only frequent injuries but also serve as an important indicator for a possibly underlying osteoporosis. Therefore, in addition to fracture management, timely diagnostics and treatment of the osteoporosis should also be prioritized. The decision between a conservative and surgical treatment approach requires a differentiated consideration of the fracture morphology, individual patient characteristics and functional expectations. Conservative treatment can be an adequate alternative in specific cases, particularly in geriatric patients with low functional demands; however, the standardization of this treatment approach remains challenging. Surgical interventions have proven effective, especially for complex fractures, with reverse shoulder arthroplasty emerging as a reliable option. Various augmentation and fixation techniques, such as the combination of locking plates with fibular grafts or double plating osteosynthesis, demonstrate biomechanical advantages and can improve the primary stability. Innovative technologies, including 3D planning, intraoperative navigation and robotics, offer new possibilities for optimizing implant placement and can contribute to improvement of long-term clinical outcomes. Economic analyses suggest that reverse arthroplasty can provide not only clinical benefits in selected cases but can also be cost-effective; however, further evaluation of the long-term impact on the healthcare system is required.

Primary stability in locking plate fixation for proximal humeral fractures may be increased by using an additional nail osteosynthesis in combination with locking plate osteosynthesis-A biomechanical comparison

BACKGROUND

Stability is regarded as an important factor for proper healing and avoiding secondary dislocation in osteoporotic fractures of the proximal humerus. Several surgical techniques have been proposed for treatment, including intramedullary nail osteosynthesis and locking plate fixation. This study introduces a novel approach that combines both techniques and compares its primary stability with conventional methods.

METHODS

The study involved 25 osteoporotic humeri with two-part fracture models, which were randomly assigned to locking-plate fixation, intramedullary nailing, or a combination of both techniques. The specimens were subjected to sinusoidal loading at 250 N in 20° abduction for 5000 cycles and then to quasi-static loading until failure. Fracture movement, failure mode, and failure load were measured and compared among the groups.

FINDINGS

The groups fixated with intramedullary nailing and the groups fixated with intramedullary nailing and locking plate fixation showed significantly lower fracture motion than the group using locking plate fixation only (p < 0.005) and significantly higher load to failure (p = 0.007 and p = 0.0062, respectively). There was no significant difference between the group using intramedullary nailing and the group using locking-plate fixation and intramedullary nailing in fracture movement or load-to-failure (p > 0.005).

INTERPRETATION

The results indicate that locking plate fixation provides less primary stability than intramedullary nailing or the combined of both techniques. This combined approach may offer advantages as a treatment for complex proximal humeral fractures in osteoporotic bone, and specific implants should be developed to ensure optimal treatment.

Biomechanical testing of osteosynthetic locking plates for proximal humeral shaft fractures - a systematic literature review

Proximal humeral shaft fractures can be treated with helically deformed bone plates to reduce the risk of iatrogenic nerve lesion. Controversially to this common surgical technique that was first established in 1999, no biomechanical investigation on humeral helical plating is recorded by other reviews, which focus on proximal fractures exclusively. Does an additional scope for shaft fractures reveal findings of helical testing? The present systematic literature review was performed based on guidelines by Kitchenham et al. to systematically search and synthesize literature regarding biomechanical testing of osteosynthetic systems for proximal humeral shaft fractures. Therefore, a systematic approach to search and screen literature was defined beforehand and applied on the findings of the database PubMed®. Synthesized information of the included literature was categorized, summarized and analyzed via descriptive statistics. Out of 192 findings, 22 publications were included for qualitative synthesis. A wide range of different test methods was identified, leading to a suboptimal comparability of specific results between studies. Overall, 54 biomechanical test scenarios were identified and compared. Physiological based boundary conditions (PB-BC) were referenced in 7 publications only. One study of testing straight and helical dynamic compression plates without PB-BCs was identified, showing significant differences under compressional loading. The absence of test standards of specific fields like humeral fractures lead to a high variance in biomechanical testing of osteosynthetic locking plates for proximal humeral shaft fractures. Physiological approaches offer realistic test scenarios but need to be uniformed for enhanced comparability between studies. The impact of helically deformed locking plates under PB-BC was not identified in literature.

"Mother and baby plate": a strategy to improve stability in proximal fractures of the ulna

INTRODUCTION

Proximal ulna fractures with a large zone of comminution, such as in the context of Monteggia injuries, require mechanically strong osteosyntheses as they occur in regions with high physiological joint load. Consequently, implant failure and pseudarthrosis are critical and devastating complications, especially with the background of mainly young patients being affected. An effective solution could be provided by adding a small second plate 90° angulated to the standard dorsal plate in the area of non-union. Thus, this study investigates whether, from a biomechanical point of view, the use of such a mini or baby plate is worthwhile.

MATERIALS AND METHODS

Comminuted fractures distal to the coronoid process, equivalent to Jupiter type IIb fractures, are generated on artificial Sawbones® of the ulna and stabilized using two different plate osteosyntheses: in the first group, a dorsal locking compression olecranon plate is used (LCP group). In the second group, a small, ulnar 5-hole olecranon plate is added as a baby plate in addition to the mother plate at the level of the fracture zone (MBP group). Dynamic biomechanical loading in degrees of flexion from 0° to 90° is carried out to determine yield load, stiffness, displacement, and changes in fracture gap width as well as bending of the dorsal plate.

RESULTS

The "mother-baby-plate" osteosynthesis had a significantly higher yield load (p < 0.01) and stiffness (p = 0.01) than the LCP group. This correlates with the increased movement of the proximal fracture element during cyclic testing for the LCP group compared to the MBP group as measured by an optical metrology system.

CONCLUSIONS

Here, we show evidence that the addition of a small plate to the standard plate is highly effective in increasing the biomechanical stability in severe fractures equivalent to Jupiter type IIb. As it hopefully minimizes complications like pseudarthrosis and implant failure and as the additional preparatory effort leading to compromised blood supply is regarded to be negligible, this justifies and highly advises the use of a mother-baby-plate system.

Dynamic biomechanical investigation of a novel sulcus bicipitalis plate in combination with a conventional locking plate for the treatment of complex proximal humerus fractures

BACKGROUND

Complex proximal humerus fractures place high demands on osteosynthetic treatment. In some cases, double plating has already been used to increase primary stability of the osteosynthesis. This approach was advanced in the present study by developing an additive plate for the sulcus bicipitalis. To demonstrate the superior primary stability of the newly developed plate osteosynthesis, a biomechanical comparison against a conventional locking plate with an additional calcar screw was performed.

METHODS

Ten pairs of cadaveric humeri were treated proximally with a locking plate (PENTA plate small fragment, INTERCUS). Each had a two-part fracture model with a fracture gap of 10 mm. All right humeri were treated with an additive novel plate that extends along the bicipital sulcus and encircles the lesser tuberosity proximally. First, the specimens were loaded sinusoidally at 250 N in 20° abduction for 5000 cycles. Afterwards quasi-static loading until failure was applied.

FINDINGS

The movement at the fracture gap due to the cyclic loading occurred mainly as rotation around the z-axis, corresponding to a tilt medially and distally. The double plate osteosynthesis reduces the rotation by approximately 39%. For all load cycles observed, except 5000 cycles, medial and distal rotation of the head was significantly reduced by the double plate. The failure loads showed no significant differences between the groups.

INTERPRETATION

In the tested scenario under cyclic loading, the novel double plate osteosynthesis showed a significant superiority of primary stability over the conventional treatment with one locking plate. Furthermore, the study showed the advantages of cyclic load application over quasi-static load application until failure.

Double Plating for Complex Proximal Humeral Fractures: Clinical and Radiological Outcomes

Double plating for proximal humeral fractures (PHF) is an option to increase the primary fixation stability. Clinical data is missing for assessment of clinical and radiological outcome, as well as complications. We retrospectively examined 35 patients with unilateral PHF, who were treated with double plating for PHF between 2013 and 2019. The mean age was 59.5 ± 12 years and the leading fracture type was a varus dislocation (Resch type IV in 55.3%). A head-split was present in 22.9% of the cases. The primary outcome measurement was the radiological neck shaft angle (NSA). The radiological follow-up was 21 ± 16.6 months and the NSA did not differ between the intraoperative and follow-up time point (131.5 ± 6.9° vs. 136.6 ± 13.7°; p = 0.267). The clinical follow-up was 29.5 ± 15.3 months. The Constant-score was 78.5 ± 17 points, the simple-shoulder-test (SST) was 9.3 ± 3.2 points and the subjective shoulder value (SSV) was 78.8 ± 19.5%. The over-all complication rate was 31.4%, and without stiffness 14.3%. An avascular necrosis occurred in two patients (5.7%). In conclusion, this study shows good radiological and functional outcomes after double plating of highly complex proximal humeral fractures, while the complication rate is comparable to the literature. Double plating is a viable option especially for younger patients with complex fractures as a potential alternative to fracture arthroplasty.

Preventing varus collapse in proximal humerus fracture fixation: 90-90 dual plating versus endosteal fibular allograft strut

INTRODUCTION

Screw cut out and varus collapse are the most common complication of locked plate fixation of proximal humerus fractures. The purpose of this study was to compare dual plating and endosteal fibular allograft struts as augmentation strategies to prevent varus collapse.

MATERIALS AND METHODS

A trapezoidal osteotomy was created at the metaphysis to create a 2-part proximal humerus model in 18 paired shoulder specimens. Each specimen was assigned to group A, B, or C and was fixed with either a lateral locking plate, a lateral locking plate and anterior one-third tubular plate in an orthogonal 90/90 configuration, or a lateral locking plate with intramedullary fibular strut, respectively. The specimens were stressed in axial compression to failure. Displacement, elastic limit, ultimate load, and stiffness were recorded and calculated.

RESULTS

There was no difference in mean cyclic displacement between the three groups (0.71 mm vs 0.89 mm vs 0.61 mm for Group A, B, C, respectively). Lateral plating demonstrated the greatest absolute and relative displacement at the elastic limit (5.3 mm ± 1.5 and 4.4 mm ± 1.3) without significance. The elastic limit or yield point was greatest for fibular allograft, Group C (1223 N ± 501 vs 1048 N ± 367 for Group B and 951 N ± 249 for Group A) without significance.

CONCLUSIONS

Dual plating of proximal humerus fractures in a 90-90 configuration demonstrates similar biomechanical properties as endosteal fibular strut allograft. Both strategies demonstrate superior stiffness to isolated lateral locked plating.

Double plating is associated with higher fixation strength than single plating in osteoporotic fractures of the scapular spine: a biomechanical study

INTRODUCTION

The number of atraumatic stress fractures of the scapular spine associated with reverse shoulder arthroplasty is increasing. At present, there is no consensus regarding the optimal treatment strategy. Due to the already weakened bone, fractures of the scapular spine require a high fixation stability. Higher fixation strength may be achieved by double plating. The aim of this study was to evaluate the biomechanical principles of double plating in comparison to single plating for scapular spine fractures.

METHODS

In this study, eight pairs (n = 16) of human shoulders were randomised pairwise into two groups. After an osteotomy at the level of the spinoglenoid notch, one side of each pair received fracture fixation with a single 3.5 LCP (Locking Compression Plate) plate. The contralateral scapular spine was fixed with a 3.5 LCP and an additional 2.7 LCP plate in 90-90 configuration. The biomechanical test protocol consisted of 700 cycles of dynamic loading and a load-to-failure test with a servohydraulic testing machine. Failure was defined as macroscopic catastrophic failure (screw cut-out, plate breakage). The focus was set on the results of specimens with osteoporotic bone quality.

RESULTS

In specimens with an osteoporotic bone mineral density (BMD; n = 12), the mean failure load was significantly higher for the double plate group compared to single plating (471 N vs. 328 N; p = 0.029). Analysis of all specimens (n = 16) including four specimens without osteoporotic BMD revealed no significant differences regarding stiffness and failure load (p > 0.05).

CONCLUSION

Double plating may provide higher fixation strength in osteoporotic bone in comparison to a single plate alone. This finding is of particular relevance for fixation of scapular spine fractures following reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Controlled laboratory study.

Primary stability of cement augmentation in locking plate fixation for proximal humeral fractures: A comparison of absorbable versus non-absorbable cement

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.

The forgotten fragment: additional lesser tuberosity fixation of 4-part proximal humeral fractures-a biomechanical investigation

BACKGROUND

Fractures of the proximal humerus are common. The most frequent surgical treatment option is open reduction and locking plate fixation. Multifragmentary fractures, including 3- and 4-part fractures, are especially challenging to treat because they correlate with an increased risk of fixation failure. In the past, several mechanisms of additional fixation were investigated, but none directly addressed the lesser tuberosity (LT). The goal of this study was to investigate the biomechanical impact of additional anterior fracture fixation in lateral locked plating (LLP) of 4-part proximal humeral fractures (PHFs).

METHODS

Twenty-seven fresh frozen human shoulder specimens (mean age, 80 years) with intact rotator cuffs (RCs) were randomized into 4 groups: 3-part PHF with LLP and RC cerclage (n = 6); 4-part PHF with LLP and RC cerclage as standard of care (n = 7); 4-part PHF with LLP, RC cerclage, and 2 anterior 3.5-mm cortical screws (n = 7); and 4-part PHF with LLP, RC cerclage, and additional anterior one-third tubular plate (additional anterior plating [AAP], n = 7). Static load of the RC was simulated with weights. A force-controlled cyclic loading test was performed with a servo-hydraulic testing machine, followed by load-to-failure testing. An optical motion capture system recorded humeral head range of motion.

RESULTS

LLP of a 4-part PHF showed more humeral head motion than LLP of a 3-part PHF without fracture of the LT (P < .001). Fixing the LT to the humeral head with two 3.5-mm screws significantly reduced humeral head motion compared with LLP with RC cerclage alone (P < .006). Using AAP significantly increased the construct stiffness compared with the standard of care (P = .03).

CONCLUSION

LLP of a 4-part PHF is biomechanically less stable than LLP of a 3-part PHF without fracture of the LT. Additional screw fixation of the LT in 4-part PHFs improves stability compared with LLP alone. In case of metaphyseal comminution, AAP is favorable from a biomechanical perspective.

Reduction and fixation of proximal humeral fracture with severe medial instability using a small locking plate

BACKGROUND

Currently, the reduction and support of comminuted medial cortex of humeral fracture remains a challenge, Therefore, a novel reduction and fixation technique that employs an anteromedial small locking plate was explored in this study, and its viability and the associated complications were assessed.

METHODS

Fifteen cases of proximal humeral fractures with medial instability (five cases were classified as three-part and ten as four-part by Neer classification) were treated by the proposed reduction technique using an anteromedial small locking plate. Subsequently, the radiological and clinical outcomes were evaluated over an average follow-up period of 18.53 months.

RESULTS

The average operation time was 108 min (range, 70-130 min), and the mean fracture union time in all patients was 12.13 weeks (range, 8-16 weeks). Complications such as infection and neurovascular injury were not observed. Postoperative X-ray showed avascular necrosis and screw penetration in one patient, while screw penetration, varus malunion, or significant reduction loss was not found in the other cases. The mean Constant score was 79.8 (range, 68-92) during the final visit.

CONCLUSIONS

The use of an anteromedial small locking plate improved the reduction efficiency, reconstructed the medial support, and alleviated the occurrence of complications in proximal humeral fractures with medial instability.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

INTRODUCTION

A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures.

PATIENTS AND METHODS

Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value.

RESULTS

After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported.

DISCUSSION

Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

A Biomechanical Model for Testing Cage Subsidence in Spine Specimens with Osteopenia or Osteoporosis Under Permanent Maximum Load

BACKGROUND

Intervertebral fusions in cases of reduced bone density are a tough challenge. From a biomechanical point of view, most current studies have focused on the range of motion or have shown test setups for single-component tests. Definitive setups for biomechanical testing of the primary stability of a 360° fusion using a screw-rod system and cage on osteoporotic spine are missing. The aim of this study was to develop a test stand to provide information about the bone-implant interface under reproducible conditions.

METHODS

After pretesting with artificial bone, functional spine units were tested with 360° fusion in the transforaminal lumbar interbody fusion technique. The movement sequences were conducted in flexion/extension, right and left lateral bending, and right and left axial rotation on a human model with osteopenia or osteoporosis under permanent maximum load with 7.5 N-m.

RESULTS

During the testing of human cadavers, 4 vertebrae were fully tested and were inconspicuous even after radiological and macroscopic examination. One vertebra showed a subsidence of 2 mm, and 1 vertebra had a cage collapsed into the vertebra.

CONCLUSIONS

This setup is suitable for biomechanical testing of cyclical continuous loads on the spine with reduced bone quality or osteoporosis. The embedding method is stable and ensures a purely single-level setup with different trajectories, especially when using the cortical bone trajectory. Optical monitoring provides a very accurate indication of cage movement, which correlates with the macroscopic and radiological results.

[Research progress on medial support augmentation of plate osteosynthesis for proximal humeral fractures]

Objective

To review the literature about the clinical application and research progress on medial support augmentation of plate osteosynthesis for proximal humeral fractures, and to provide reference for clinical treatment.

Methods

The literature concerning medial support augmentation of plate osteosynthesis for proximal humeral fractures in recent years was extensively reviewed, as well as the biomechanical benefit and clinical advantage were analyzed thoroughly.

Results

Medial support augmentation of plate osteosynthesis for proximal humeral fractures is very important, especially in osteoporotic and/or comminuted fractures. Many medial support augmentation methods have been proposed which can be divided into extramedullary support and intramedullary support. It can also be divided into autogenous bone support and allogenic bone support according to the material and source, divided into medial column support, calcar support, and humeral head support according to the support site, and divided into fibular shaft support, femoral head support, anatomic fibula support according to the shape of the augmented fixation. At present, clinical and biomechanical researches show that medial support augmentation is an effective treatment for proximal humeral fractures.

Conclusion

As an important treatment strategy for the treatment of proximal humeral fractures, the medial support augmentation of plate osteosynthesis gets the focus from the biomechanical studies and clinical treatment. However, there are still widespread controversies among orthopedic surgeons regarding the support mode, site, implant shape, and material of medial column support for augmentation of proximal humeral fractures. More high-quality clinical trials and biomechanical researches as well as multi-disciplinary integration, are needed to provide better strategy treatment for the treatment of proximal humeral fractures.

Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery

BACKGROUND

The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques.

AIMS

The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery.

HYPOTHESES

1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed.

METHODS

Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria.

RESULTS

The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures.

CONCLUSION

There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.

The plate fixation strategy of complex proximal humeral fractures

PURPOSE

For complex proximal humeral fractures, severe displacement and comminuted fragments lead to poor clinical outcomes. Despite considerable management, the locking plate fixation is still a preference and the proper selection of its strategy for each individual seems to be essential.

METHOD

The available classification system of the fracture, determination of surgical intervention, the common complications and related causes, and the latest critical surgical strategies with locking plate fixation were discussed in this review.

RESULTS

The frequent complications with complex proximal humeral fractures after operative treatment present a great challenge to orthopedic surgeons. In order to maintain the stability of locking plate fixation, several options including calcar screw, bone graft, bone cement augmentation, dual plate fixation, and fracture impaction were available for restoration of medial support.

CONCLUSION

Restoration of medial support seems of importance to provide solid stability and reduced complication for the complex fractures with fixation of locking plates.

Biomechanical behavior of three types of fixation in the two-part proximal humerus fracture without medial cortical support

Background

The purpose of this study was to evaluate the role of a non-locking plate applied to the anteromedial surface of the proximal humerus on loads at the implant-bone interface of non-locking and locking lateral plate fixation of proximal humeral fractures with a medial gap.

Methods

Twenty synthetic humeri models were used. In fifteen, the proximal portion of the humerus was osteotomized to create a two-part surgical neck fracture, with a 10-mm medial gap and a 5-mm lateral gap; five models were controls. In the osteotomized humeri, five models were stabilized with a locking lateral plate (group L), five with a locking lateral plate and an anteromedial non-locking plate (group L+T), and five with a non-locking lateral plate and a non-locking anteromedial plate (group T+T). All humeri were tested under axial loading until catastrophic failure, which was characterized as complete closure of the medial gap. Stiffness was calculated using force vs. displacement curves. The data were analyzed via descriptive and inferential studies, at a 5% significance level.

Results

Statistically significant differences were seen among all the constructions. The combination of a lateral locking plate with an anteromedial non-locking plate (group L+T) was the stiffest construction, while the combination of a non-locking lateral plate with a non-locking anteromedial plate (group T+T) was the least stiff, even in comparison with a single locking lateral plate (p = 0.01). When the two groups which utilized a lateral locking plate (groups L+T and L) were compared, the group with additional anteromedial support demonstrated greater stiffness (p = 0.03), and stiffness values for the control group comprised of intact humeri models were even higher (p = 0.01).

Conclusion

Combining a lateral locking plate with a non-locking anteromedial plate provides a stiffer construction for fixation of unstable two-part proximal humerus fractures with a medial gap. Mechanical benefits of medial support with a second non-locking antero-medial plate seems to be related with better construct stability in terms of strength and fatigue, potentially reducing the risk of varus collapse of the humerus head and fracture healing disturbances.