Fibular strut allograft influences reduction and outcomes after locking plate fixation of comminuted proximal humeral fractures in elderly patients: a retrospective study

Abstract

Background: Proximal humeral fractures (PHFs) are the third most commonly occurring fractures in elderly patients. Most of these fractures can be treated with conservative methods, but the optimal surgical treatment strategy for unstable fractures in elderly patients remains controversial. This study aimed to compare the radiological and clinical outcomes between locking compression plate (LCP) fixation and LCP fixation with fibular allograft implantation for the treatment of comminuted PHFs.

Methods: We retrospectively reviewed 60 patients (mean age, 72.75 years) with closed 3- or 4-part fractures, and a minimum of 2 years of follow-up. Fracture reduction was quantitatively determined by humeral head height (HHH) and neck-shaft angle (NSA). The clinical outcome was evaluated by Constant-Murley score (CMS) and American Shoulder and Elbow Surgeons (ASES) score.

Result: The average radiological changes were higher in the LCP group than in the locking plate with fibular allograft group (HHH of 4.16 mm vs 1.18 mm [p < 0.001] and NSA of 9.94° versus 3.12° [p < 0.001]) . The final average outcome scores were lower in the LCP group than in the FA group (CMS of 73.00 vs 78.96 [p = 0.024] and ASES score of 72.80 vs 78.64 [p = 0.022]). The FA group showed better forward elevation (p = 0.010) and abduction (p = 0.002); however, no significant differences were observed for shoulder external rotation or internal rotation. The number of complications was higher in the LCP group (28.57%) than in the FA group (1.2%) (p < 0.001).

Conclusion: For comminuted PHFs in elderly patients, LCP fixation combined with a fibular allograft is reasonable option to ensure satisfactory radiological and clinical outcomes.

Trial registration: ZDYJLY(2018)New-9 . Name of registry: IEC for clinical Research of Zhongda Hospital, Affiliated to Southeast University. Date of registration: 2018-05-17.

Keywords: Elderly patients; Fibular allograft; Locking plate; Proximal humeral fracture.

Fig. 1

Calculation of the humeral head height. The two lines drawn running perpendicular to the shaft of the plate; one was placed at the top edge of the plate, and the other was placed at the superior edge of the humeral head. The distance between these two lines was measured and designated as the head height

Fig. 2

The head-shaft alignment (angle α) was determined as follows: a first line (dashed line) was drawn from the superior border to the inferior border of the articular surface and a second line was drawn perpendicular to the first line through the center of the humeral head. A third line bisected the humeral shaft, and the angle between the second and third line was defined as the head-shaft angle α

Fig. 3

The reduction and fixation process with a fibular strut allograft. a A 1.5 mm guidewire was placed 1 cm posterior to the intertubercular groove and 1 cm medial to the transition between the head and the greater tuberosity. b The fibular allograft was inserted into the cavity, through the fracture site, through the guidewire. And then, it was pushed upwards to support the humeral head in a proper height. c After confirming the fracture reduction, a LCP was used to fix the fragments. Locking screws were placed through the graft into the humeral head and shaft. d Post-operative radiograph showing good anatomical reduction

Fig. 4

surgical procedure (a, b) Holes were drilled on the fibular allograft to make the fibula easily maneuvered into position. c The fibular allograft was inserted into the cavity through the bone defect. d Without the exposure of medial calcar, the medial column could be indirectly reduced to pushing the fibular allograft upwards. e A proximal locking plate was used to fix the greater tuberosity to the humeral head. f Multiple non-absorbable sutures were passed to compress comminuted fragments to the bony defect of the proximal humerus

Fig. 5

A case of a 3-part fracture with severe metaphyseal comminution. a Radiograph of a displaced 3-part humeral fracture in the left shoulder of a 73-year-old woman. b CT scan, 3-D reconstruction view. (c, d) Radiograph 1 year after surgery

Fig. 6

Clinical function 2 years after surgery. a Active abduction. b Active forward elevation. c Active external rotation. d. Active internal rotation