PROXIMAL HUMERAL FRACTURES TREATED WITH LOCKED PLATING AND AN INTRAMEDULLARY STRUT

ALLOGRAFT:A RETROSPECTIVE ANALYSIS

BRIAN L. BADMAN MD

JONATHAN LEVY MD

RANDALL OTTO MD

MARK MIGHELL MD

DISCLOSURES:

• BRIAN BADMAN MD

• PAID CONSULTANT, ROYALTIES, INVESTOR UPEX

• PAID CONSULTANT DJO SURGICAL

• JONATHAN LEVY MD

• PAID CONSULTANT DJO SURGICAL, ARTHREX, STRYKER ORTHOPAEDICS

• RANDALL OTTO MD

• HONORARIUM DJO SURGICAL

• MARK MIGHELL MD

• PAID CONSULTANT, ROYALTIES, INVESTOR UPEX

• PAID CONSULTANT DJO SURGICAL

BACKGROUND

• LOCKED PLATING: TREATMENT OPTION FOR PROXIMAL HUMERAL FRACTURES

• IMPLANT COMPLICATIONS : SCREW CUTOUT AND VARUS RELATIVELY COMMON

• ENDOSTEAL ALLOGRAFT STRUT FOR REDUCTION AND MEDIAL CALCAR RESTORATION

BACKGROUND

• 27 PATIENTS

• 23 FIBULA AND 4 SEMITUBULAR PLATES

• 96% PATIENTS MAINTAINED REDUCTION

• CONCLUSION:

• ENDOSTEAL IMPLANT WITH LOCKING PLATE CAN AVOID VARUS COLLAPSE

Locked Plating of the Proximal Humerus Using an Endosteal Implant

Hettrich, Neviaser, Beamer et al; 2012; 26(4); 212-215

Proximal Humeral Fracture Fixation: Locking Plate Constuct +/- Intramedullary fibular allograft

Chow, Begum, Beaupre, Carey2012 Jul;21(7):894-901

• 16 CADAVER HUMERII

• 8 LOCKING PLATE + FIBULA, 6 COLLAPSED

• 8 LOCKING PLATE ONLY, 0 COLLAPSED

• LOADED TO FAILURE OR 25,OOO CYCLES

• CONCLUSION:

• PLATE + FIBULA BETTER WITHSTANDS VARUS LOADING

HYPOTHESIS:

• LOCKED LATERAL PLATING COMBINED WITH AN INTRAMEDULLARY ALLOGRAFT FOR THE TREATMENT OF PROXIMAL HUMERUS FRACTURES WOULD BE SIMILAR TO PUBLISHED STUDIES AND MITIGATE VARUS COLLAPSE

METHODS

• RETROSPECTIVE ANALYSIS OF ALL 2-,3- AND 4-PART FRACTURES TREATED WITH LOCKED PLATING AND INTRAMEDULLARY ALLOGRAFT• 2PART—19(30%)• 3PART—33(50%)• 4PART—13(20%)

• MINIMUM ONE YEAR CLINICAL F/U

• 65 PATIENTS

• AVG AGE 68YRS

METHODS

• XRAYS REVIEWED BY INDEPENDENT OBSERVER

• ASSOCIATIONS BETWEEN PATIENT AND FRACTURE SPECIFIC FACTORS

• AGE (>65 OR < 65YRS)

• FRACTURE TYPE (2, 3, OR 4-PART)

• HERTEL CRITERIA (>8MM OR <8MM MEDIAL HINGE)

• GENDER

• ASES SCORE

• SHOULDER ROM USING GONIOMETER.

RESULTS

• AVG F/U 22 MONTHS (RANGE: 12-53)

• AVERAGE ASES SCORE: 79 (RANGE: 15-100)

• AVERAGE ROM

• FF: 125° (RANGE: 40°-180°)

• EXTERNAL ROTATION: 39° (RANGE: 0°-90°)

• HERTEL CRITERIA—MEDIAL HINGE

• 46 (71%) <8MM

• 19 (29%) >8MM

• MEAN HUMERAL NECK SHAFT ANGLE: 127° (RANGE, 104°-145°)

• 100% UNION• AVG TIME: 4.2M (RANGE: 1.5-8M)

RESULTS

• OVERALL COMPLICATION RATE: 18% (12/65)

• FRACTURE MALUNION: 15% (10/65)

◦ 2 GREATER TUBEROSITY AVULSIONS

◦ 8 VARUS MALUNIONS (12%)

- 2 PATIENTS WITH VARUS MALUNIONS ALSO HAD SCREW PENETRATION

• SCREW PENETRATION: 6% (4/65)

• AVASCULAR NECROSIS: 3% (2/65)

• NO STATISTICAL DIFFERENCE IN FUNCTIONAL OUTCOME, COMPLICATION RATE OR INCIDENCE AVN BASED ON AGE, GENDER, OR FRACTURE TYPE.

CONCLUSION• ALLOGRAFT STRUT HELPFUL AS REDUCTION AID AND INITIAL STABILITY IN

SITUATIONS OF METAPHYSEAL AND MEDIAL CALCAR COMMINUTION

• VARUS COLLAPSE WAS NOT DIMINISHED BY USE OF AN ALLOGRAFT STRUT

• UTILITY OF THIS TECHNIQUE IN “SOLVING” THIS PROBLEM IS QUESTIONED

• REVISION SURGERY HARDER

• AVOIDANCE OF THIS COMPLICATION IS LIKELY MULTIFACTORIAL RELATED TO TECHNICAL FACTORS (MEDIAL SUPPORT, CALCAR SCREWS, ETC) AND PATIENT FACTORS (OSTEOPOROSIS, PATIENT COMPLIANCE, ETC)

THANK YOU