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Displacement/Screw Cutout After Open Reduction and Locked Plate Fixation of Humeral Fractures
Kevin C. Owsley, MD1; John T. Gorczyca, MD1
1 University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642. E-mail address for J.T. Gorczyca: john_gorczyca@urmc.rochester.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Zimmer). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at the University of Rochester Medical Center, Rochester, New York

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Feb 01;90(2):233-240. doi: 10.2106/JBJS.F.01351
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Abstract

Background: Fixation of proximal humeral fractures is challenging. Locking plate technology offers mechanical advantages for treating unstable fractures in weak bone. In this study, we assessed the radiographic and clinical results of a single surgeon's experience treating proximal humeral fractures with a locked proximal humeral plate.

Methods: Fifty-three adult patients with a displaced proximal humeral fracture were treated with a proximal humeral locking plate over a forty-five-month period. A standard postoperative rehabilitation regimen was followed. Radiographs were made at two weeks, six weeks, three months, six months, and one year and were examined for fracture alignment, fracture displacement, hardware position, and healing. Postoperative outcomes were collected with questionnaires.

Results: Fifty-two (98%) of the fifty-three fractures healed by six months. Nineteen patients (36%) had radiographic signs of a complication, including screw cutout with intra-articular displacement in twelve (23%), substantial (>10°) varus displacement in thirteen (25%), and osteonecrosis in two (4%). These radiographic signs of a complication occurred in twelve (57%) of twenty-one patients older than sixty years of age and in seven (22%) of thirty-two patients under sixty years of age (p = 0.0015). Screw cutout occurred in nine (43%) of the twenty-one patients older than sixty years. Patients with a complication had worse functional outcomes as measured with the Short Musculoskeletal Function Assessment (p < 0.05) and the Quick Disabilities of the Arm, Shoulder and Hand (p < 0.001) questionnaires. We were unable to demonstrate a relationship between fracture type and complications. Revision surgery was performed in seven (13%) of the fifty-three patients. There were no cases of infection, nerve injury, or hardware failure.

Conclusions: The use of locking plates in the surgical treatment of proximal humeral fractures is associated with an unexpectedly high rate of screw cutout and revision surgery, especially in patients older than sixty years who have a three or four-part fracture. The indications for open reduction and internal fixation in these patients require continued analysis.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    John T Gorczyca, M.D.
    Posted on May 25, 2008
    Dr. Gorczyca, et al. respond to Dr. Kolb, et al.
    University of Rochester Medical Center, Rochester, NY

    We thank the Doctors Kolb for their interest in our article “Displacement/Screw Cutout after Open Reduction and Locked Plate Fixation of Proximal Humeral Fractures,”(1) and we appreciate their technical tips.

    We agree that anatomical reduction of the fracture, especially the medial cortex, is important, and we also agree that it is important to achieve anatomical reduction of the tuberosities.

    Whether or not to use indirect means to reduce the surgical neck component of the fracture is a matter of surgical style and personal preference. The available literature does not support the idea that the fracture must be anatomically reduced “prior to the placement of the hardware.” Please see our detailed response to the letter by Badman and Mighell(2).

    When comminution or compression of the medial cortical bone precludes obtaining a load-sharing anatomic reduction of the medial side of the proximal humerus, we agree with efforts to augment medial stability using well-positioned inferomedial screws, intramedullary plates, or intramedullary allograft struts. We are wary that the reference which best supports the use of well-positioned inferomedial locking screws is retrospective; the fourteen year age difference between patients with medial support compared to those without medial support makes us less confident that locking screws placed into the inferomedial head, by themselves, will eliminate screw cutout(3). References to intramedullary plates are anecdotal at best(4). Reports describing the use of intramedullary allograft struts are still preliminary(5).

    We remain optimistic that improved methods for successful head- preserving treatment of proximal humerus fractures will emerge. We caution against overenthusiastic adoption of these techniques before they have withstood clinical scrutiny.

    References:

    1. Owsley KC, Gorczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg 2008;90:233-240.

    2. . Owsley KC, Gorczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg 2008;90:233-240. [Letter to the Editor] J Bone Joint Surg Am. epub 10 Apr 2008. http://www.ejbjs.org/cgi/eletters/90/2/233.

    3. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21:185-91.

    4. Sperling JW, Cuomo F, Hill JD, Hertel R, Chuinard C, Boileau P. The difficult proximal humerus fracture: tips and techniques to avoid complications and improve results. Instr Course Lect 2007;56:52.

    5. Gardner MJ, Boraiah S, Helfet DL, Jorich D. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma 2008;22:195-200.

    Werner Kolb, M.D.
    Posted on April 25, 2008
    More technical tips for locking compression plate fixation of proximal humerus fractures
    Isolde-Kurz-Str. 50, 70619 Stuttgart Germany

    To The Editor:

    We read with great interest the article entitled “Displacement/Screw Cutout After Open Reduction and Locked Plate Fixation of Humeral Fractures"(1). We have used the LCP for six years and we would like to offer some technical tips.

    1) The proximal humerus fracture must be anatomically reduced or slightly impacted reduced prior to placement of the hardware(2). It is most important to reduce and to fix the tuberosities with their muscle insertions as closely as possible to their original anatomical sites(3).

    2) Restoration of the medial hinge is critical to successful anatomic healing of the proximal humerus fracture(2). A disrupted medial hinge must be reduced and can be reconstituted with a 2.0 mm intramedullary plate(4).

    3) In cases of comminution or malreduction of the medial hinge, the placement of calcar-specific screws (to within 5 mm of the subchondral bone) is critical to support the medial column and therefore maintain fracture reduction(5).

    4) If calcar screws are necessary, the plate must be positioned to ensure that the screw will purchase the inferior part of the calcar(5).

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Owsley KC, Gorczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of humeral fractures. J Bone Joint Surg Am. 2008;90:233-240.

    2. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humerus fractures based on current literature. J Bone Joint Surg Am. 2007;89(Suppl 3)(Oct):44-58.

    3. Szyskowitz R. Humerus: proximal. In Rüedi TP, Murphy WM, editors. AO principles of fracture management. New York: Thieme;2000:270-289.

    4. Sperling JW, Cuomo F, Hill JD, Hertel R, Chuinard C, Boileau P. The difficult proximal humerus fracture: tips and techniques to avoid complications and improve results. Instr Course Lect. 2007;56:52.

    5. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma 2007;21:185-91.

    John T. Gorczyca, M.D.
    Posted on April 08, 2008
    Re: Some Technical Points Regarding Use of Locked Plate Fixation of Humeral Fractures
    University of Rochester Medical Center, Rochester, NY

    We thank Drs. Badman and Mighell for sharing their input regarding our series which reports a high rate of fracture displacement and screw cutout after locked plate fixation of proximal humerus fracture(1). It is likely that other surgeons share similar concerns, but have not expressed them. It was our understanding that publishing a paper which reports an unexpectedly high complication rate is likely to draw criticism, but given the nature and frequency of the complications, we considered it important to report our findings and technique in order that other surgeons may learn and their patients benefit from our experience. We will address your concerns individually.

    1. Quality of Reduction: We agree that anatomic reduction is important. Figure 1 shows a fracture with non-anatomic medial reduction in which screw cutout occurred. This case was chosen because it clearly demonstrates the screw cutout. At the time of this patient’s surgery, such a complication had not been described with locked proximal humerus plating, so this finding was not “expected”. Conversely, our belief at the time was that proximal humerus fractures fixed with locking plates would behave like periarticular fractures of the distal femur and proximal tibia, in which the use of plates with multiple locking screws were reported to have improved stability against axial mal-alignment and low rates of fixation loss. As we reported, this was not our experience with locked plate fixation in the proximal humerus.

    As you point out, Gardner et al. report a lower rate of screw cutout when “medial support” of the proximal fracture was achieved (5% vs. 29%), which supports the notion that anatomic reduction will minimize complications such as screw cutout(2). One must bear in mind that the patients in that study who had medial support were on average 14 years younger (55 vs. 69 years), which suggests that advanced age and weaker bone quality may impair the surgeon’s ability to achieve medial bony contact intraoperatively. The concept that medial support is difficult to achieve in severe osteoporosis is supported by your recommendation of structural bone allograft to fill large metaphyseal voids: if anatomic reduction could reliably prevent fixation loss and screw cutout, then why would one need the structural allograft? Like you, we are optimistic that structural allograft may have a place in the operative treatment of proximal humerus fractures, but the specific uses and techniques are in the early stage of development(3).

    2. Locking Plate as a Reduction Tool: It is correct that in many cases we fixed the plate to the proximal humerus first, and then reduced the surgical neck out of varus alignment by fixing the plate to the bone with non-locking screws first. Our early experience was that even with anatomic reduction and provisional K-wire fixation of these fractures, the muscular forces on the proximal humerus would cause the surgical neck component to drift into varus before the fracture could be definitively stabilized. Our use of the locking plate as a reduction tool eliminated that problem. It appears that Badman and Mighell have misinterpreted the studies that they reference. Haidukewych’s review pertained to Less Invasive Stabilization System (LISS) plates, which, unlike proximal humerus locking plates, were designed for percutaneous insertion and fixation with only locking screws, such that reduction was not possible after the plate had been locked on both sides of the fracture(4). Smith et al. comment that when one uses plates that have only locking holes, the bone segment cannot be manipulated after it has been locked to the plate(5). Later in the report, however, they describe the use of conventional screws through non-locking holes “to pull the bone to the plate initially to secure a fracture reduction.” Moreover, all of the x- rays in Gardner et al’s. report appear to have non-locking screws that were used to pull the humeral shaft to the plate(2). Thus, the use of the locking plate as a reduction tool is beneficial and in accordance with basic principles of fracture management.

    3. Locking screw angle and position: The writers point out that the locking plates that we used in our series have locking screws that do not match the anatomic neck shaft angle of the humerus. This is true. It is unlikely that designing a plate with locking screws that match the neck shaft angle (and thus are parallel to each other) would decrease the likelihood of screw cut-out (indeed, that would decrease resistance to fracture displacement, and perhaps increase the likelihood of screw cutout). We disagree with the contention that “the majority of the screws are placed into the superior part of the head where the weakest bone is located.” The plates that were used in our series were designed to distribute screw fixation throughout the humeral head. There is conflicting data on the strength of the bone in the superior humeral head, so fracture fixation which distributes the screws into multiple regions of the humeral head seems to be a logical approach for maximizing fixation strength(6-7).

    Like Drs. Badman and Mighell, we are hopeful that techniques will evolve that will minimize the risk of complications with internal fixation of proximal humerus fractures. However, we caution against overly enthusiastic adoption of techniques that have not yet withstood clinical scrutiny.

    References:

    1. Owsley KC, Gorczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of humeral fractures. J Bone Joint Surg Am. 2008;90:233-240.

    2. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21:185-91.

    3. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect Medial Reduction and Strut Support of Proximal Humerus Fractures Using an Endosteal Implant. J Orthop Trauma. 2008; 22:195-200.

    4. Haidukewych GJ. Innovations in Locking Plate Technology J. Am. Acad. Ortho. Surg., July/August 2004; 12: 205 - 212.

    5. Smith WR, Ziran BH, Anglen JO, Stahel PF. Locking plates: tips and tricks. J Bone Joint Surg Am. 2007 Oct;89(10):2298-307. Review.

    6. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of Screw Placement on Fixation in the Humeral Head. J Shoulder Elbow Surg. 2000 Sept-Oct; 9(5):423-6.

    7. Hepp P, Lill H, Bail H, Korner J, Niederhagen M, Haas NP, Josten C, Duda GN. Where Should Implants be Anchored in the Humeral Head? Clin Orthop and Rel Research, (415)139-147, 2003.

    Brian L. Badman, M.D.
    Posted on February 26, 2008
    Some Technical Points Regarding Use of Locked Plate Fixation of Humeral Fractures
    OrthyIndy, Danville, IN

    To The Editor:

    We read with interest the article entitled "Displacement/Screw Cutout After Open Reduction and Locked Plate Fixation of Humeral Fractures"(1). We wish to provide some important technical considerations in managing these difficult fractures.

    The fixation of proximal humeral fractures has been aided greatly by the advent of anatomical fixed-angle locking plates. While recent publications by Rose et al.(2) and the current authors have documented alarmingly high failure rates when treating proximal humeral fractures with locking osteosynthesis, we would contend that the surgical technique utilized to treat these injuries is just as critical, if not more important, than the fixation device utilized.

    We commend the current authors for their utilization of suture fixation of the tuberosities. Many authors have failed to stress the importance of this and if surgeons are depending on screw fixation alone, the fracture construct will likely fail. By tying the tuberosities to the plate, the basic principles of hemiarthroplasty are followed and the natural deforming forces of the rotator cuff are counterbalanced. Omitting this step can result in a substantially high rate of fracture displacement.

    Our main critique of the article is based on the radiographic example of the "acceptable" reduction of the four-part valgus impacted fracture. As pointed out by Gardner(3), reproduction of the medial hinge and in essence, anatomical reduction of the fracture prior to application of the plate is of utmost importance. In the x-ray presented by the authors, the fracture was clearly never adequately reduced out of valgus impaction. Furthermore, the screws placed into the head appear to have displaced the fragment further medially from the plate resulting in further mal-alignment. As would be expected, when the fracture settled the screws cut out. We would contend that had the fracture been reduced, this outcome might have been avoided. As a technical pearl, we have found that in situations where a large metaphyseal void exists after elevation of the head in these circumstances, a piece of structural allograft in the form of a tricortical iliac crest graft or fibular strut can be placed in an intramedullary position to fill the void and provide adequate head support and help prevent head collapse.

    We would also like to comment on the authors' recommendation of using the locking plate as a reduction tool to reduce the head fragment to the shaft. While this can occasionally be utilized in younger (stronger) bone, we do not recommend this technique for use in older (osteoporotic) bone, the more likely case when dealing with this type of injury. This technique also violates the basic AO tenet of locked plate osteosynthesis where the fracture should be reduced first and the plate never utilized as an indirect reduction tool.(4,5).

    Finally, we would like to point out that all current published series of hardware cutout have been in situations where the locking plate is fixed with screws that do not match the anatomic neck shaft angle of the humerus(2,3). Many of the manufacturers have essentially mimicked the initial design of the Synthes Philos plate (Synthes, Ltd Paoli, PA) thereby creating more of a blade plate design and necessitating a higher placment on the shaft. In doing so, the majority of the screws are placed into the superior part of the head where the weakest bone is located. This may predispose these plate designs to higher failure rates and, by using a plate that is positioned lower, more fixation in the stonger inferior hemisphere may be obtained thereby potentially reducing these complications.

    In conclusion, we believe that the technique of fixation of these fractures is critical and that by following a systematic approach with basic principles the results of fixation of these difficult fractures will continue to improve with locked plate technology.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Owsley KC, Groczyca JT. Displacement/screw cutout after open reduction and locked plate fixation of humeral fractures. J Bone Joint Surg Am. 2008;90:233-240.

    2. PS Rose, Adams CR, Torchia ME, Jacofsky DJ, Haidukewych GG, Steinmann SP. Locking plate fixation for proximal humeral fractures: initial results with a new implant. J Shoulder Elbow Surg. 2007 Mar-Apr;16(2):202-7.

    3. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007 Mar;21(3):185-91.

    4. Haidukewych GJ.Innovations in Locking Plate Technology J. Am. Acad. Ortho. Surg., July/August 2004; 12: 205 - 212.

    5. Smith WR, Ziran BH, Anglen JO, Stahel PF. Locking plates: tips and tricks. J Bone Joint Surg Am. 2007 Oct;89(10):2298-307. Review.

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