Proximal humeral fractures pose a challenge to orthopedic surgeons. Their incidence has increased 13% in the past three decades, and they remain the third most common fracture seen in the elderly population.1,2 With the aging of the population, the incidence of these complex fractures will likely continue to rise.1,2 Treatment remains difficult and is guided by the nature and complexity of the fracture. Initially described by Neer,3 the number of “parts” associated with the fracture plays a critical role in treatment. Treatment options include nonoperative management, open reduction and internal fixation (ORIF), or arthroplasty. Construct failure is always possible, but 3- and 4-part fractures, which represent 23% of proximal humerus fractures, may be more prone to failure and poor results.1,2,4–6
Use of ORIF is generally favored over shoulder arthroplasty in younger patients. In elderly patients for whom ORIF is used, locking plate technology is often necessary, given poor bone density.6 However, locking plate technology is not without issue, and complication rates as high as 50% have been reported.7–11 Complications include varus collapse, avascular necrosis (AVN), intra-articular screw penetration, and subacromial impingement. Even with anatomic reduction, complication rates as high as 10% have been reported.5,12–15 These complications increase the risk for revision surgery.7–10,13,16 Initial varus fracture alignment has been shown to increase complication rates threefold in fractures treated with locking plate ORIF.16–18 This is likely secondary to medial calcar comminution and the inability of the proximal humerus to resist compressive loads.6,19–21 Several biomechanical studies have validated this theory, demonstrating increased load to failure and less displacement using bone graft or cortical bone struts to augment and stabilize the calcar.13,20,22–24
High failure rates after ORIF with locked plating have led to exploration of other preventive adjuncts. Gardner et al25 were the first to describe the addition of a fibular allograft to traditional locking plate ORIF to improve stability and prevent varus collapse. In their initial study, they reported no loss of reduction and noted eventual incorporation of the surrounding allograft. Several others have since corroborated their results, with fibular strut allografts being successful in preventing major complications, including varus collapse and AVN.26–32 Patient-reported outcomes have also shown improvement using a fibular allograft.33,34 Hinds et al27 attributed this to the additional stability achieved using a fibular strut, allowing for earlier intense therapy. To the current authors’ knowledge, no direct head-to-head comparison exists evaluating complication rates following locking plate ORIF with or without a fibular allograft strut. The purpose of this study was to compare the radiographic head shaft angle (HSA) as well as complication and revision rates between fibular allograft and locking plate only groups. The authors hypothesized that the addition of a fibular allograft would decrease rates of varus collapse and revision surgery, particularly in more complex 3- and 4-part fractures.
Materials and Methods
Following institutional review board approval, the authors retrospectively reviewed adult patients 18 years or older from their level I trauma institution’s database who had undergone ORIF with or without a fibular allograft for 2-, 3-, or 4-part proximal humerus fractures during a 5-year period. Exclusion criteria were prior proximal humerus fracture or shoulder injury, surgery performed 3 or more weeks after injury, no follow-up past union or revision surgery, lack of radiographs at initial or final postoperative visits, or neurologic disorder of the ipsi-lateral arm. After exclusion of 7 patients who did not meet follow-up requirements, a total of 133 patients (47 male and 86 female) were subdivided into a locking plate only (LP) group (72 patients) and a locking plate plus fibular allograft (FA) group (61 patients). Additional demographic information is presented in Table 1.
Demographic and Injury Data
Fracture characteristics based on Neer’s classification, as well as intact calcar length, were evaluated on injury radiographs (Figure 1) and are presented in Table 2. Additional surgical variables, including type of approach (deltopectoral vs deltoid splitting), time from injury to surgery, and fluoroscopy time, were reviewed. The primary outcome measure was the change in HSA from initial postoperative to final follow-up radiographs. Secondarily, the authors analyzed rates of collapse, complication, and revision and differences related to fracture complexity.
Anteroposterior radiograph of a 72-year-old woman who had a widely displaced proximal humerus fracture as the result of a motor vehicle collision.
Fracture and Surgical Data
The addition of a FA was based on surgeon discretion. Factors noted in operative reports contributing to FA use included age, osteoporosis, and fracture complexity. The cost of each 10-cm allograft was $645. A deltopectoral or a deltoid-splitting approach with the patient in the supine position was chosen based on surgeon comfort, and these approaches were not notably different when assessing strut use (P=.14). In the FA group, the allograft was inserted through the lateral metaphyseal comminution, with the superior allograft near the center of the humeral head (Figure 2). Inserting the graft laterally through the existing comminution caused by the injury helped avoid additional soft tissue stripping and allowed the strut to stabilize the fracture while the tuberosities were rotated into place (Figure 3). Fluoroscopy was used for fracture reduction, and Kirschner wires were placed. A PHILOS plate (Synthes, West Chester, Pennsylvania) was placed, with fluoroscopy confirming its position. The plate was fixed with cortical screws distally and locking screws proximally with every attempt made to obtain calcar screw fixation. In 89% of cases, Ethibond (Johnson & Johnson, Somerville, New Jersey) or FiberWire (Arthrex Inc, Naples, Florida) suture was used to fixate tuberosity fragments to the plate. Postoperatively, a sling was placed and only pendulum exercises were allowed until follow-up.
Anteroposterior radiograph at 12-month follow-up of the patient from Figure 1 showing successful fracture healing without displacement.
Clinical photograph of the final fixation construct as visualized through a lateral deltoid-splitting approach.
At the initial follow-up visit, 2 weeks postoperatively, radiographs were obtained and the HSA was measured. In the FA group, additional measurements performed included vertical FA length, distance from the superior FA to the superior humeral head, and distance from the medial FA to the center of the humeral head. Follow-up visits occurred at regular intervals thereafter, with radiographs obtained at each. The HSA was measured and the change in the HSA from initial postoperative to final postoperative radiographs was calculated. Varus collapse was defined as a difference in HSA of 10° or more. The number of weeks to varus collapse was recorded. Evidence of intraarticular screw cutout, AVN, hardware failure, or screw loosening was also noted on radiographs, and the need for revision surgeries was recorded. Each complication was also analyzed based on fracture complexity.
After data collection, statistics were analyzed, with means, ranges, and confidence intervals calculated for continuous variables, and compared using Student’s t tests. Frequencies were calculated for continuous variables and compared using Fisher’s exact test for increased accuracy in small proportion analysis. P<.05 was considered significant.
Demographically, differences were noted only in age, sex, and history of osteoporosis. The FA group was 8 years older (P<.01), more likely female (P=.04), and more commonly osteoporotic (P=.01). Average follow-up for the LP group and FA group was 26 and 31 weeks, respectively (P=.26).
No differences were seen in the proportions of 2-, 3-, or 4-part fractures between groups (P=.58). Based on measurements on injury radiographs, 80% of the LP group had a calcar fragment measuring greater than 8 mm, while this was present in only 64% of the FA group (P=.04). Fluoroscopy time was lower in the FA group, at 63 seconds, compared with the LP group, at 80 seconds (P=.04). Significantly more locking screws were used in the proximal segment of the FA group, although the absolute increase (6.4 for FA vs 5.9 for LP) was minimal (P<.01).
Radiographic data comparing the FA and LP groups are listed in Table 3. The HSA at final follow-up was significantly higher in the FA group (P=.01); the LP group demonstrated an average 4.7° decrease in HSA compared with the FA group, which only decreased 1.8° (P=.03). Change in HSA in the LP and FA groups is compared in Figure 4 and Figure 5, respectively. A nonsignificant trend was noted toward collapse greater than 10° in the LP group (P=.06), but when the threshold was increased to greater than 20°, there was no difference (P=.37). Average time to collapse was 22 weeks. No significant differences were noted between the LP and FA groups regarding intra-articular screw penetration, AVN, hardware failure, or screw loosening, but overall complication rates were low. Secondary surgery was necessary in 7 patients in the LP group and included 5 revisions, 1 arthroplasty, and 1 hardware removal, while only 1 hardware removal was performed in the FA group. The differences in secondary surgery rate did not reach statistical significance with the study population (P=.12).
Anteroposterior radiographs at initial (A) and final (B) follow-up for a patient in the locking plate only group demonstrating a 22° decrease in head shaft angle.
Anteroposterior radiographs at initial (A) and final (B) follow-up for a patient in the locking plate plus fibular allograft group demonstrating only a 5° decrease in head shaft angle.
A subgroup analysis of 3- and 4-part fracture patterns revealed no significant differences in demographic variables except for the FA group being older (65 vs 54 years, P=.02). Although a 25-minute decrease in operative time in the FA group was nonsignificant (P=.25), fluoroscopy time did decrease significantly in the FA group (P=.05). Number of screws and the remaining variables did not demonstrate any differences. However, at final follow-up, there was a significantly greater HSA (P=.05) and less change in HSA from initial radiographs in the FA group (P=.05). There was also a significant difference in revision surgery rates for 3- and 4-part fractures, with a 16% incidence in the LP group and no revisions in the FA cohort (P=.05).
This study demonstrated support for the authors’ hypothesis, noting significantly greater final HSA (P=.01) and less HSA loss in the FA group at final follow-up (P=.03). These results are consistent with prior reports, which have detailed high rates of varus collapse following proximal humerus fractures treated with ORIF using only a locking plate.5,7–12,14,15 Some studies have noted an initial HSA of less than 120° as having higher risk for collapse and failure.16–18 The current study found initial radiographs with similar HSAs between the LP (129°) and the FA (130°) groups. Despite this, the LP group showed a significant increase in degree of varus collapse postoperatively; 13% of the patients in the LP group showed varus collapse greater than 10°, compared with only 3% in the FA group. Use of the fibular allograft was initially popularized after Gardner et al25 reported no loss of reduction. Several authors have affirmed a reduction of varus collapse with its use, supporting the current authors’ conclusions.26,28,29,32,33
Several factors influence the progression of varus collapse, including medial comminution, calcar discontinuity, and low bone density.5,6,10,19 Ponce et al20 demonstrated that medial comminution decreased construct load to failure by 48%. Contrarily, use of a fibular allograft is intended to increase medial support in the proximal humerus region.30 Several studies demonstrated increased load to failure using a fibular allograft to augment a locking plate construct, and others have since shown decreases in displacement and loss of reduction of the proximal fragment with a fibular allograft.21–24,35,36 Interestingly, the current study found that 64% of the FA group had a calcar fragment greater than 8 mm, compared with 80% of the LP group (P=.04). These findings may represent higher likelihood of using a fibular allograft in cases of medial comminution for the aforementioned reasons. Nonetheless, there was still less change in the HSA (P=.03) and fewer cases of collapse in the FA group. Osteoporosis was present in 18% and 4% of the FA and LP groups, respectively, indicating surgeons’ preference for additional augmentation in this population.
In addition to varus collapse, other modes of failure in proximal humerus fractures include AVN, intra-articular screw penetration, and reoperation. In a systematic review, Brorson et al7 noted rates of intra-articular screw penetration from 5% to 20% and an AVN rate up to 33%. Sproul et al9 noted higher complication rates, up to 49%. In their review with LP only fixation, AVN and screw perforation were noted in 10% and 8%, respectively. These results have since been corroborated by many others, indicating high rates of radiographic complication with relatively poor clinical outcomes.6,8,10,16–18,37 The current study did not identify any significant differences in the rate of AVN, screw breakage, or screw loosening between the two groups. However, given the overall number of complications, this study may have been under-powered in representing any differences. Reoperation was necessary in 7 patients (10%) in the LP group and only 1 (2%) in the FA group (P=.07). There was 1 symptomatic hardware removal in each group, and 5 revision ORIF procedures were performed in the LP group secondary to construct failure.
Further, fracture complexity is important, as 3- and 4-part fractures have been cited as having higher complication rates.1,2,4–6 Presumably, FA augmentation may be helpful to increase construct stability, as mentioned above. The current results support this, as there were significant improvements in HSA and a smaller decrease in HSA at final follow-up in the FA group. Of particular interest was the finding that FA insertion significantly decreased risk of revision, with no 3- or 4-part fractures in the study requiring revision ORIF and a 16% incidence of revision ORIF being noted in the 3- or 4-part LP group. For these reasons, this subset of fractures may be particularly well suited for FA augmentation.
Although the current authors are unaware of other studies comparing LP and FA in a clinical setting, Zhu et al34 compared iliac bone graft with a LP with a LP only; the bone graft group had improved clinical outcomes, although no radiographic comparisons were made. Several other studies have substantiated good clinical and radiographic outcomes with the use of FA in small series.26–32 The results of the current study were consistent with these previous non-comparative studies. The authors were able to demonstrate a higher final HSA in the FA group compared with the LP group (P=.01), as well as a higher degree of varus collapse in the LP group (13%) vs the FA group (3%).
There were several limitations to this study. First, a larger sample may have allowed the authors to better evaluate their secondary radiographic outcome measures, as these complications were relatively uncommon in both cohorts. Second, there are inherent limitations to the study’s retrospective nature. A prospective double-blinded study should ideally be performed to further establish clinical relevance. Selection bias may have also been present based on the severity of the initial fracture, length of intact calcar, and varus alignment on original radiographs, leading to increased FA use in complex fracture patterns. Despite this potentially negative bias, results from the FA group were superior or non-inferior in nearly every category. A cost analysis of FA was not performed. The cost of FA should be compared with the cost of revision after failure in LP groups in future studies. Finally, the current study did not evaluate clinical outcome scores. It would be of value to quantify outcome measures to better understand whether radiographic markers of complication are consistent with clinical outcomes. The addition of a fibular allograft may also create difficulties when revision surgery is needed for infection or placement of arthroplasty components, and this also warrants future investigation.
Patients with proximal humerus fractures undergoing ORIF are at risk for varus collapse, especially in the setting of medial calcar comminution. Augmentation with the use of a FA compared with the use of a LP alone appears to decrease the risk of varus collapse as represented by the ability to better maintain HSA radiographically. The use of FA may also be beneficial in decreasing revision rates in more complex 3- and 4-part fracture patterns secondary to the additional stability imparted. Further prospective trials are recommended to examine long-term effects and clinical outcomes related to these radiographic markers.
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Demographic and Injury Data
|Variable||No Strut (n=72)||Fibular Strut (n=61)||P|
|Age, mean±SD (range), y||54.3±18.1 (18–92)||62.3±11.2 (35–86)||<.01|
|Male, No.||31 (43.1%)||16 (26.2%)||.04|
|Tobacco use, No.||42 (58.3%)||30 (49.2%)||.30|
|Body mass index, mean±SD (range), kg/m2||28.9±7.9 (16.0–55.6)||28.1±8.4 (16.5–57.4)||.55|
|Side, right, No.||32 (44.4%)||27 (44.3%)||.98|
|Dominant side, No.||29 (40.3%)||28 (45.9%)||.73|
|Diabetes, No.||15 (20.8%)||14 (22.9%)||.83|
|History of osteoporosis, No.||3 (4.2%)||11 (18.0%)||.01|
|Follow-up, mean, wk||26.0||31.3||.26|
Fracture and Surgical Data
|Variable||No Strut (n=72)||Fibular Strut (n=61)||P|
|Ipsilateral scapular fracture, No.||12 (16.7%)||5 (8.2%)||.19|
|Isolated fracture, No.||23 (32.9%)||30 (49.2%)||.06|
|Calcar fragment >8 mm, No.||58 (80.1%)||39 (63.9%)||.04|
|Time from injury to surgery, mean±SD (range), d||2.1±2.7 (0–14)||4.0±5.3 (0–29)||<.01|
|Surgical approach (delto-pectoral), No.||28 (38.9%)||16 (26.2%)||.14|
|Estimated blood loss, mean±SD (range), mL||163.2±164.1 (30–1000)||198.0±149.8 (25–700)||.23|
|Fluoroscopy time, mean±SD (range), sec||80.0±61.9 (8–295)||62.5±32.2 (14–151)||.04|
|Screw, mean±SD (range), No.|
| Proximal/head||5.9±1.2 (3–9)||6.4±0.9 (5–8)||<.01|
| Diaphyseal||3.4±0.7 (3–6)||3.3±0.6 (2–5)||.10|
|Fracture classification, No.|
| 2-part||47 (65.3%)||35 (57.4%)||.58|
| 3- or 4-part||25 (34.7%)||26 (42.6%)|
|Variable||No Strut (n=72)||Fibular Strut (n=61)||P|
|Final head shaft angle, mean±SD (range)||124.4°±10.0° (82°–147°)||128.4°±5.2° (117°–140°)||.01|
|Change in head shaft angle, mean±SD (range)||4.7°±8.5° (0°–50°)||1.8°±5.6° (0°–27°)||.03|
|Coronal collapse, No.|
| >10°||9 (12.5%)||2 (3.3%)||.06|
| >20°||4 (5.6%)||1 (1.7%)||.37|
|Avascular necrosis, No.||2 (2.8%)||4 (6.5%)||.44|
|Screw breakage, No.||3 (4.2%)||2 (3.3%)||.79|
|Screw loosening, No.||3 (4.2%)||2 (3.3%)||.79|
|Revision surgery, No.||7 (9.7%)||1 (1.7%)||.07|
| 2-part||3 (6.4%)||1 (2.9%)|
| 3- or 4-part||4 (16%)||0 (0.0%)||<.01|