Improved outcomes for proximal humerus fracture open reduction internal fixation augmented with a fibular allograft in elderly patients: a systematic review and meta-analysis

Extended Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Meta-Analysis

BACKGROUND

There is growing interest in extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA); however, the benefit of EAP remains controversial. For this investigation, both oral and intravenous antibiotic protocols were included in the EAP group.

METHODS

The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, Ovid Embase, Elton B. Stephens CO, and Cumulative Index to Nursing and Allied Health Literature were queried for literature comparing outcomes of primary and aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients who were treated with either ≤24 hours of postoperative antibiotic prophylaxis (standard of care [SoC]) or >24 hours of EAP. The primary outcome was periprosthetic joint infection (PJI). A pooled relative-risk random-effects Mantel-Haenszel model was implemented to compare cohorts.

RESULTS

There were 18 studies with a total of 19,153 patients included. There was considerable variation in antibiotic prophylaxis protocols with first-generation cephalosporins being the most commonly implemented antibiotic for both groups. Patients treated with EAP were 35% less likely to develop PJI relative to the SoC (P = .0004). When examining primary TJA, patients treated with EAP were 39% and 40% less likely to develop a PJI for TJA (P = .0008) and THA (P = .02), respectively. There was no significant difference for primary TKA (P = .17). When examining aseptic revision TJA, EAP led to a 36% and 47% reduction in the probability of a PJI for aseptic revision TJA (P = .007) and aseptic revision TKA (P = .008), respectively; there was no observed benefit for aseptic revision THA (P = .36).

CONCLUSIONS

This meta-analysis demonstrated that patients treated with EAP were less likely to develop a PJI relative to those treated with the SoC for all TJA, primary TJA, primary THA, aseptic revision TJA, and aseptic revision TKA. There was no significant difference observed between EAP and SoC for primary TKA or aseptic revision THA.

The relationship between humeral head angulation and bone void within the humeral head in proximal humerus fractures

Background

The variability of humeral head angulation in proximal humerus fractures (PHFs) is a noteworthy observation. The purpose of this study was to investigate the potential association between humeral head angulation and bone void within the humeral head in PHFs.

Methods

We used the reconstruction function in Mimics software to generate three-dimensional models of fractures. Bony landmarks were employed to accurately define the calcar and humeral head zone. Boolean subtraction was performed to calculate the volume of head bone void.

Results

The cohort consisted of 60 (74.1 %) varus, 21 (25.9 %) valgus, and 23 (22.1 %) neutral angulated PHFs. The mean percentage of humeral head bone void was 38.5 ± 17.8 in varus, 36.3 ± 15.7 in valgus, and 30.1 ± 10.6 in neutral angulated PHFs. A significant difference was observed between the varus and neutral groups (P = 0.035). In addition, an analysis of humeral head bone void was conducted among patients aged over 65 years old, revealing a mean percentage of 42.7 ± 16.4 in varus (27 cases), 34.8 ± 14.5 in valgus (13 cases), and 28.1 ± 11.8 in neutral (8 cases) angulated PHFs. The difference between the varus and neutral groups was also significant (P = 0.023).

Conclusion

All types of angulation patterns exhibited humeral head bone void to some extent, with the varus-displaced PHFs demonstrating more obvious defects in comparison to the neutral angulated type.

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Methods

The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed.

Results

A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group.

Conclusion

While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

Allografts use in orthopedic surgery: trend change over the past 11 years from a regional tissue bank

Allografts are the second most transplanted tissue in medicine after blood and are now increasingly used for both primary and revision surgery. Allografts have the advantages of lower donor site morbidity, availability of multiple grafts, and shorter operative time. The Banks represents the bridge between Donor and Recipient and guarantees the quality and safety of the distributed allografts Given the increasing interest in these tissues, a retrospective analysis of data collected from the Regional Musculoskeletal Tissue Bank registry over an 11-year period (2009-2019) was conducted. The statistical analyses used were the Shapiro-Wilk normality test and a Poisson regression model. From January 2009 to December 2019, a total of 14,199 musculoskeletal tissues stored in the Regional Musculoskeletal Tissue Bank were provided for surgical allograft procedures. In 2009, the number of allografts performed was 925; this figure has steadily increased to 1599 in 2019. Epiphyses were taken as the reference tissue with an almost constant trend over the period, while a significant increase was denoted for extensor mechanism allograft, ligaments, tendons and long bone corticals (p < 0.001), processed bone tissues had no change in trend (p = 0.841). There was also a gradual decrease in the rate of microbiological positivity, as determined by bacteriological and serological tests performed on the collected tissues. This phenomenon is due to improved sampling techniques and the training of a dedicated team. Thus, we have seen how the use of allografts in orthopedic surgery has increased over the past 11 years, uniformly in terms of tissue type, except for the noticeable increase in ligamentous tissue.

Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis

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).

Endosteal strut using a hydroxyapatite/poly-L-lactide mesh tube with a proximal humeral locking plate for the treatment of proximal humeral fractures

PURPOSE

Proximal humeral fractures cause large intramedullary bone defects after humeral-head reduction. Hydroxyapatite/poly-L-lactide (HA/PLLA) materials are widely used for various fractures. However, the efficacy of endosteal strut using a HA/PLLA mesh tube (ES-HA/PLLA) with a locking plate for treating proximal humeral fractures was not reported. The purpose of this study is to examine the efficacy of ES-HA/PLLA with a proximal humeral locking plate in proximal humeral fractures.

METHODS

Seventeen patients with proximal humeral fractures treated using ES-HA/PLLA with a locking plate from November 2017 to November 2021 were evaluated. The range of motion of the shoulder and postoperative complications were assessed at the final follow-up. Radiographs were evaluated to assess bone union and loss of reduction by measuring humeral-head height (HHH) and humeral neck-shaft angle (NSA).

RESULTS

The average flexion and external rotation of the shoulder at the final follow-up were 137° (range, 90-180°) and 39° (range, - 10 to 60°), respectively. All fractures were united. The average HHH and NSA just after the surgery and final follow-up were 12.5 mm and 11.6 mm and 129.9° and 127.4°, respectively. Two patients presented screw perforation of the humeral head. One patient underwent implant removal due to infection. Avascular necrosis of the humeral head was observed in one patient with arthritis mutilans.

CONCLUSIONS

The use of ES-HA/PLLA with a proximal humeral locking plate resulted in bone union in all patients and prevented postoperative loss of reduction. ES-HA/PLLA is one of the treatment options for proximal humeral fractures.

Biomechanical evaluation of novel intra- and extramedullary assembly fixation for proximal humerus fractures in the elderly

Purpose: A novel intra- and extramedullary assembly fixation method was introduced, which achieved good clinical results in complex proximal humeral fractures; however, evidence of its comparability with traditional fixation is lacking. This biomechanical study aimed to compare it with traditional fixation devices in osteoporotic proximal humeral fractures. Methods: Three-part proximal humeral fractures with osteopenia were created on 12 pairs of fresh frozen humerus specimens and allocated to three groups: 1) lateral locking plate, 2) intramedullary nail, and 3) intra- and extramedullary assembly fixation. The specimens were loaded to simulate the force at 25° abduction. Thereafter, an axial stiffness test and a compound cyclic load to failure test were applied. Structural stiffness, number of cycles loaded to failure, and relative displacement values at predetermined measurement points were recorded using a testing machine and a synchronized 3D video tracking system. Results: In terms of initial stiffness and the number of cycles loaded to failure, the intra- and extramedullary assembly fixation group showed notable improvements compared to the other groups (p <0.017). The mean relative displacement value of measurement points in the intra- and extramedullary assembly fixation group was smaller than that in the other two groups. However, there was no significant difference until 10,000 cycles. The mean relative displacement of the intramedullary nail group (3.136 mm) exceeded 3 mm at 7,500 cycles of loading. Conclusion: In this test model, axial fixation can provide better mechanical stability than non-axial fixation. The intra- and extramedullary assembly fixation is better able to prevent the varus collapse for elderly proximal humeral fractures with posteromedial comminution.

Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws

BACKGROUND

Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome.

MATERIAL AND METHODS

Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated.

RESULTS

51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030).

CONCLUSION

This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Current concepts of bone grafting in trauma surgery

Bone graft in trauma surgery is commonly used in managing bone defects, non-union, fracture related infections, arthrodesis or to provide structural support in fractures. A variety of bone grafts are made available to the treating physician, which includes autograft, allograft and bone graft substitutes. The future of bone grafting in trauma surgery is exciting with the incorporation of technological advancement such as gene therapy, 3D-printing and tissue engineering. Regardless, there are still limitations to what we understand regarding current bone grafting techniques with conflicting literature on their clinical utility and indication. The aim of this review article therefore is to take a step back and critically evaluate the current concepts of bone grafting in trauma surgery, with special emphasis made on reviewing the types of bone graft, biology of bone graft incorporation and indication for its use in various clinical scenarios.

Age-Related changes in the morphological features of medial column of the proximal humerus in the Chinese population

Background

Age-related changes in the medial column (MC) of the proximal humerus have a major impact on fracture management; however, the changes in the morphological features remain unclear. This study aimed to investigate the age-related changes in the morphological features of MC and present the morphological grading.

Methods

One hundred computed tomography (CT) images of the proximal humerus of 100 individuals (19-95 years) were retrospectively obtained. The individuals were categorized into five age groups to quantify the differences among different ages; the youngest group (18-44 years) served as the baseline group. Parameters of the morphological features were measured on CT images with multiplanar reconstruction based on an explicit definition of MC, including length, thickness, width, oblique thickness (DSM), humeral head diameter (DHM), and ratio (RSM) of DSM to DHM. The morphological grading of MC was presented based on the value of RSM deviating different standard deviations (SD) from the mean value in the baseline group.

Results

Significant negative correlations were observed between age and the morphological parameters of MC (r ranged from -0.875 to -0.926; all P < 0.05), excluding DHM (r = 0.081, P = 0.422). Significant differences in the values of morphological feature parameters were detected among the five age groups (all P < 0.001). The highest mean values of morphological feature parameters were observed in the youngest group (18-44 years), which decreased gradually with increasing age until the lowest mean values were observed in the oldest group (≥90 years) (all P < 0.05). The morphological features of MC were categorized into three grades based on the value of RSM deviating 1.5 SD or 3 SD from the mean value in the baseline group.

Conclusion

Our study shows that the parameter values of morphological features of MC decreased with increasing age. The morphological features of MC could be categorized into three grades. Our findings may provide a more comprehensive insight into age-related changes in the morphological features of MC that facilitate risk stratification and optimize the management of proximal humeral fractures.

Effect of Fibular Allograft Augmentation in Medial Column Comminuted Proximal Humeral Fractures: A Randomized Controlled Trial

BACKGROUND

Previous observational studies and meta-analyses have recommended augmentation with a fibular allograft (FA) during the treatment of proximal humeral fractures with locking plates (LPs). However, to our knowledge, randomized controlled trials comparing open reduction and internal fixation (ORIF) with and without FA have not been performed to date.

METHODS

This was a randomized controlled trial in which adults with a medial column comminuted proximal humeral fracture were randomly allocated to undergo ORIF with an LP (the LP group) or with an LP augmented with an FA (the FA group). Patients were followed for 24 months. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months after the surgical procedure. The secondary outcomes included the DASH score at other time points, shoulder function, pain score, satisfaction, complications, and changes in neck-shaft angle and humeral head height.

RESULTS

From October 20, 2016, to December 24, 2019, 80 patients were randomized. There were 52 women (65%), and the mean patient age (and standard deviation) was 65 ± 14 years. Of the 80 patients, 39 were allocated to the FA group and 41 were allocated to the LP group. At the primary time point (12 months), the unadjusted mean between-group difference in DASH score was -1.2 (95% confidence interval [CI], -7.3 to 5.0; p = 0.71) favoring the FA group, and, with adjustment for smoking, alcohol drinking, and diabetes, the between-group difference was -1.4 (95% CI, -7.7 to 5.0; p = 0.67) favoring FA. No significant differences between the 2 groups were found among the secondary outcomes.

CONCLUSIONS

No additional benefit was found for FA augmentation in treating medial column comminuted proximal humeral fractures.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Treatment Reality of Proximal Humeral Fractures in the Elderly-Trending Variants of Locking Plate Fixation in Germany

BACKGROUND

The surgical treatment of proximal humeral fractures (PHFs) with locking plate fixation (LPF) in the elderly is associated with high complication rates, especially in osteoporotic bone. Variants of LPF such as additional cerclages, double plating, bone grafting and cement augmentation can be applied. The objective of the study was to describe the extent of their actual use and how this changed over time.

METHODS

Retrospective analysis of health claims data of the Federal Association of the Local Health Insurance Funds was performed, covering all patients aged 65 years and older, who had a coded diagnosis of PHF and were treated with LPF between 2010 and 2018. Differences between treatment variants were analyzed (explorative) via chi-squared or Kruskal-Wallis tests.

RESULTS

Of the 41,216 treated patients, 32,952 (80%) were treated with LPF only, 5572 (14%) received additional screws or plates, 1983 (5%) received additional augmentations and 709 (2%) received a combination of both. During the study period, relative changes were observed as follows: -35% for LPF only, +58% for LPF with additional fracture fixation and +25% for LPF with additional augmentation. Overall, the intra-hospital complication rate was 15% with differences between the treatment variants (LPF only 15%, LPF with additional fracture fixation 14%, LPF with additional augmentation 19%; p < 0.001), and a 30-day mortality of 2%.

CONCLUSIONS

Within an overall decrease of LPF by approximately one-third, there is both an absolute and relative increase of treatment variants. Collectively, they account for 20% of all coded LPFs, which might indicate more personalized treatment pathways. The leading variant was additional fracture fixation using cerclages.

Intrinsic Cortical Property Analysis of the Medial Column of Proximal Humerus

OBJECTIVE

Adequate mechanical support of the medial column is paramount to maintain fracture reduction in locking plating of proximal humerus fractures. However, intrinsic cortical properties of the medial column are rarely discussed. The purpose of the study is to describe regional variation of cortex in the medial column.

METHODS

A total of 147 healthy participants were eligible for enrollment between December 2016 and December 2018. Subjects were divided into three groups: group A (20-39 years), group B (40-59 years), and group C (>60 years). For each individual, a color 3D thickness map for proximal humerus was created by cortical bone mapping (CBM) technique after bilateral shoulders were imaged by computed tomography. Measurement Indices including the cortical thickness (CTh), cortical mass surface density (CM) and the endocortical trabecular density (ECTD) were determined, after six regions of interest (ROI) were defined in metaphyseal region. Regional parameter variations were analyzed by one-way ANOVA.

RESULTS

The CTh, CM and ECTD values were approximately equivalent between genders in the proximal part of the medial column across all ages (P > 0.05).The greatest difference between sexes was found in CTh and CM values of middle and distal part (P < 0.05). The CTh and CM within medial column were negatively associated with age (P < 0.05). The proximal cortical bone of the medial column was thicker and more dense, compared to the lateral column (P < 0.05). Significant regional variation was found in all measured parameters in group A, but not in groups B and C.

CONCLUSION

Our finding proved that regional differences in the distribution of cortical bone in the medial column The attenuation of cortical bone heterogeneity in the medial column was found after the age of 40 years.

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.

The "Three in One" Bone Repair Strategy for Osteoporotic Fractures

In aging society, osteoporotic fractures have become one major social problem threatening the health of the elderly population in China. Compared with conventional fractures, low bone mass, bone defect and retarded healing issues of osteoporotic fractures lead to great difficulties in treatment and rehabilitation. Addressing major concerns in clinical settings, we proposed the "three in one" bone repair strategy focusing on anti-osteoporosis therapies, appropriate bone grafting and fracture healing accelerating. We summarize misconceptions and repair strategies for osteoporotic fracture management, expecting improvement of prognosis and clinical outcomes for osteoporotic fractures, to further improve therapeutic effect and living quality of patients.