Chinese Medical Journal 2014;127(9):1672-1676:10.3760/cma.j.issn.0366-6999.20133104
Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture

Zhu Lian, Liu Yueju, Yang Zongyou, Li Han, Wang Juan, Zhao Changping, Chen Xiao and Zhang Yingze

Keywords
fixed-angle locked plating; proximal humerus comminuted fracture; iliac crest bone
Abstract
Background Although the use of an intramedullary fibular allograft together with locking plate fixation can provide additional medial support and prevent varus malalignment in displaced proximal humeral fractures with promising results, the fibular autograft donor site often sustains significant trauma and cannot restore the articular surface of comminuted fractures. The aim of this study was to evaluate the clinical and radiographic outcomes of a locking plate and crest bone autologous graft for treating proximal humerus comminuted fractures.
Methods We assessed the functional outcomes and complication rates in 40 patients with proximal humerus comminuted fractures. Eighteen patients were treated with a locking plate and an autologous crest bone graft (experimental group), and 22 were treated with only the locking plate and no bone graft (control group). Postoperative assessments included radiographic imaging, range of motion analysis, pain level based on the visual analogue scale (VAS), and the SF-36 (Short Form (36) Health Survey), as well as whether patients could return to their previous occupation.
Results All fractures healed both clinically and radiologically in the experimental group. There was no more than 2 mm collapse of the humeral head, and no osteonecrosis or screw penetration of the articular surface. In contrast, two patients had a nonunion in the control group, and they eventually accepted total shoulder replacements. The average time from surgery to radiographic union was significantly shorter in the experimental group ((4.66±1.63) months) compared with the control group ((5.98±1.57) months) (P <0.05). For the experimental versus controls groups, the mean shoulder active flexion (148.00±18.59 vs. 121.73±17.20) degrees, extension (49.00±2.22 vs. 42.06±2.06) degrees, internal rotation (45.00±5.61 vs. 35.00±3.55) degrees, external rotation (64.00±9.17 vs. 52.14±5.73) degrees, and abduction (138.00±28.78 vs. 105.95±15.66) degrees were all significantly higher (all P <0.001). The median SF-36 in the experimental group ((88.00±5.71) points) was significantly higher than that of the control group ((69.45±9.45) points; P <0.001). The median VAS pain level (mean rank, 10.50) in the experimental group was lower than that (mean rank, 47.19) of the control group (P <0.001). All but one patient (17 of 18, 94.4%) in the experimental group returned to their previous activities or occupations, and that one patient changed to a different occupation because of slight restrictions to activities. On the other hand, four patients could not return to their previous activities or occupations in the control group.
Conclusion Locking plate fixation combined with an iliac crest bone graft is an effective technique for treating proximal humerus comminuted fractures.
Proximal humerus fractures account for 5%–8% of all fractures.1Although more than 80% of these fractures can heal without surgical intervention, comminuted fractures remain a huge challenge for even the most experienced upper extremity surgeon. In such cases, the bone quality is frequently poor and the bone stock is often limited. In addition, patients often have multiple confounding comorbidities.2,3Although many treatment options have been described, reported outcomes are variable, and no definitive surgical solution has been identified.4Locking plate fixation has the potential to provide greater fixation than standard internal fixation techniques, especially in proximal humerus comminuted fractures. In recent years,adequate mechanical support of the medial column in the treatment of such fractures has been repeatedly emphasized,5-9which can be achieved by placing a superiorly directed oblique locking screw in the inferomedial region of the proximal fragment and inserting an intramedullary fibular allograft.10,11However, the fibular allograft operation usually causes significant trauma in the donor site. Thus, iliac crest bone grafting may be an effective alternative method. The purpose of this study was to identify whether patients treated with locking plate fixation and an iliac crest bone graft had better shoulder functional recovery than those without the bone graft.
METHODS
Patients
Between September 2009 and December 2011, 40 patients with proximal humerus comminuted fractures presented to the trauma center of our hospital and randomly either underwent ORIF (open reduction and internal fixation) using a fixed-angle locked plate and iliac crest bone graft (18 patients, experimental group) or only had open reduction and fixed-angle locked plate fixation (22 patients, control group). Confirmation of the comminuted fracture was made by both X-ray and computed tomography imaging. Patients with evidence of arthrosis or a clinical follow-up shorter than 12 months were excluded. All the fractures were defined as “four-part fractures” according to the Neer classification.12The medical comorbidities of each patient, including diabetes, chronic obstructive pulmonary disease, coronary artery disease, and hypertension, were graded according to the American Society of Anesthesiologists (ASA) classification.13
Operative techniques
The operative techniques in the experimental group were performed essentially as previously described.14All the operations were performed by one of the investigators (Zhao CP). During the operation, each patient was placed supine on the radiolucent table. One-percent iodine was used to disinfect the surgical area (including the entire upper arm and the iliac donor site) followed by swabbing with 75% alcohol iodothyronine and sterile towels draping. The autologous iliac crest bone was first harvested from the ipsilateral side. A nearly 7-cm incision was made just below the anterior iliac wing, which was parallel to the iliac crest and centered over the iliac tubercle. Next, the skin was retracted to identify the iliac crest, and an incision was made down onto it with a scalpel by stripping off the muscle from either the inner or outer wall of the ilium. Following the contour of the bone, a sharp dissection was carefully made to avoid straying out of the plane and into the soft tissue. While coming around the corner of the crest onto the ilium, the dissection was extended using a Cobb elevator to obtain a complete block of the ilium, which was nearly 3.5 cm × 2.0 cm in the present study (Figure 1). Care should be taken with the inguinal ligament during the operation, as retraction of this ligament may cause an inguinal hernia. The wound was closed with a negative-suction drain, which was removed 48 hours after the operation.
Using a deltopectoral approach, the fracture was exposed. The autologous iliac crest bone was used as a medial strut augment. The ilium strip was inserted into the medullary cavity, and the comminuted great and small tuberosities were easily fixed to the iliac crest graft. The humeral fracture fragments were temporarily fixed by Kirschner wires, which were eventually changed to a fixed-angle locked plate and screws for definitive fixation (<Figures 2–4). The wound was closed after meticulous repair of the rotator cuff.
The operative techniques applied in the control group were the same as in the experimental group, except for the bone graft procedure.
Postoperative management
Cefuroxime (2.0 g) was given pre-operatively, followed by two additional doses during the first 24 hours postoperatively. The arm was supported in a sling. Pendular movements were started on the first postoperative day and the shoulder was mobilized with passive assisted exercises, followed by active exercises after 3 weeks.
Follow-up
Clinical and radiographic follow-ups were performed at 1, 2, 6, 12, 24, 36, and 48 months postoperatively. The minimum follow-up duration was 13 (average, 25.4; range, 13–48) months. The clinical examination included assessment of the range of motion (ROM) of the affected extremity by goniometer, classification of pain according to the visual analog scale (VAS) from 0 to 10 and the SF-36 survey (Short Form (36) Health Survey).15Whether each patient returned to their previous activities or occupation was also recorded.
Statistical analysis
The data were analyzed with the use of SPSS 13.0 for Windows (SPSS Inc., Chicago, Illinois, USA). The one sample Kolmogorov-Smirnov test was applied to analyze the continuous variables. For normally distributed data, probability values were calculated with the analysis of variance. The Mann-Whitney test was used to determine the significance for the abnormally distributed data. Student-Newman-Keuls tests were applied for pairwise comparison of quantitative data, and Chi-square tests were applied for pairwise comparison of qualitative data. AP<0.05 was considered statistically significant.
RESULTS
Patients characteristics
The average age of the patients was 51 years (range, 38–62 years), and 24 patients were female and 16 were male. There were no statistical differences between the experimental and control groups based on age, sex, or medical comorbidity (ASA classification) (Table 1).
Clinical features
There were no postoperative infections in any of the patients. All the fractures received nearly anatomical reductions, as defined by <5° of varus or valgus alignment in the AP (anteroposterior) view with rigid internal fixation (Figures 5 and 6). All fractures healed both clinically and radiologically in the experimental group. There was no collapse of the humeral head by more than 2 mm, and no osteonecrosis or screw penetration of the articular surface in the experimental group. However, two patients had a nonunion in the control group, and they were eventually treated with total shoulder replacements. The average follow-up duration was 25.4 months (range, 13–48 months). The average time from surgery to radiographic union was significantly shorter in the experimental group ((4.66±1.63) months) compared with the control group ((5.98±1.57) months) (P<0.05, Table 2).
After the operation, the ROM measurements of the experimental group were all significantly larger than those of the control group (allP<0.001), including mean active flexion ((148.00±18.59) vs. (121.73±17.20) degrees), extension ((49.00±2.22) vs. (42.06±2.06)) degrees, internal rotation ((45.00±5.61) vs. (35.00±3.55) degrees), external rotation ((64.00±9.17) vs. (52.14±5.73) degrees), and abduction ((138.00±28.78) vs. (105.95±15.66) degrees). The median SF-36 in the experimental group ((88.00±5.71) points) was significantly higher than that in the control group ((69.45±9.45) points,P<0.001). The median VAS pain level (mean rank, 10.50) in the experimental group was significantly lower than that (mean rank, 47.19) of the control group (P<0.001, Table 2). All but one patient (17 of 18, 94.4%) returned to their previous activities or occupations, and that one patient, from the experimental group, changed to a different occupation because of slight restrictions to activities. In contrast, four patients could not return to their previous activities or occupations in the control group.
DISCUSSION
Compared with the shoulder function found in the control group, the patients treated with locking plate fixation and an iliac crest bone graft in the experimental group had better results in the preliminary clinical tests. This suggests that locking plate fixation and an iliac crest bone graft may be an effective method for the treatment of comminuted fractures of the proximal humerus.
Proximal humerus comminuted fractures are extremely difficult to treat. For all practical purposes, ORIF remains the treatment of choice for such fractures at many orthopedic trauma centers.4,12Because of the inherent difficulties of obtaining stable fixation in comminuted fractures, standard plating techniques have been associated with high failure rates. Although several other methods have resulted in improved treatment outcomes in small patient cohorts, many results have not been reproducible.16-20The addition of an autograft results in noted improvement in union rates, especially for fibular autografts. Although the fibular autograft can provide more biomechanical stability, the donor site often sustains significant trauma and cannot restore the articular surface for comminuted fractures.21-24When compared with fibular grafts, iliac crest bone has a lower incidence rate of donor site morbidity secondary to graft harvest,25,26and the comminuted great and small tuberosities can be easily fixed to it, which is especially helpful for reduction of comminuted fractures.
Based on a review of the literature, the most consistent technique for the treatment of proximal humeral comminuted fractures involves the use of a fixed-angle device, such as a blade plate or a proximal humeral locking plate, among others.27The difficulties with blade plates are that they can be cumbersome to apply and time consuming to bend, with the potential for implant prominence and persistent pain. Anatomic plates, on the other hand, have lower profiles, which may reduce impingement and can provide multiple divergent proximal screw options that allow for improved fixation in the compromised bone. More stable fixation could speed up the healing process by increasing the stiffness and reducing the motion at the fracture site.28Therefore, anatomic plates were chosen for internal fixation in the present, prospective study.
While designing the study, we noticed that many patients with proximal humerus fractures had a considerable number of medical comorbidities, such as diabetes, chronic obstructive pulmonary disease, coronary artery disease, and hypertension. The status of medical comorbidities will undoubtedly affect surgical outcomes; hence, we must find a method to account for the medical comorbidities in the control and experimental groups in order to isolate the effects of the surgical treatment for proximal humeral comminuted fractures. The ASA13score was chosen for comparison of medical comorbidities in our study because it is simple, practical, and effective. The ASAscore is divided into the following five levels: a normal healthy patient, a patient with mild systemic disease, a patient with severe systemic disease, a patient with severe systemic disease that is a constant threat to life, and a moribund patient who is not expected to survive without the operation. In our study, the status of each patient was classified by ASA level, and then statistical analysis was carried out to compare the comorbidities between the control and experimental groups. ThePvalue of 0.935 indicated no significant difference. ThisPvalue indicates that the results are likely due to the surgical treatment. In addition, all the operations were performed by a senior orthopedic trauma doctor, who completes nearly 100 cases of surgery for proximal humerus fracture annually. This setup avoids the influence of variability because of different surgeons’ skills and experience on the results.
The iliac crest bone grafting improved fixation, added bone stock and support to the head fragment, and provided conditions for the fixation of the great and small tuberosities, which could explain the good outcomes of our study. A handful of doctors have reported that encountering a comminuted fracture in the proximal humerus is an indication to abort the ORIF and proceed with prosthetic replacement. Although hemiarthroplasty and reverse shoulder replacement remain potential options in situations where the humeral head is severely compromised,29,30we feel that preservation of the native joint is critical for relatively young patients.
This study has some limitations. First, this study was limited by a small sample size, which prevented the observation of the incidence of donor site morbidity secondary to iliac crest graft harvest. Second, the average age of this cohort of patients was relatively young, which may explain the good results. Third, the follow-up time in our study is relatively short, which limits our ability to find long-term complications such as humeral head necrosis and shoulder instability. All of these issues need to be solved in the next multi-center randomized prospective study with a larger sample size.
In summary, proximal humerus comminuted fractures can be treated effectively with the use of locking plate fixation combined with an iliac crest bone graft. This surgical technique can result in satisfactory radiological and functional outcomes with an acceptable complication rate.
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(Received December 3, 2013)
Edited by Hao Xiuyuan

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Figure 1. Autologous ilium strip for grafting.
Figure 2. Ilium strip is inserted into the medullary cavity.
Figure 3. Ilium strip was temporarily fixed with Kirschner wire.
Figure 4. Fixed-angle locked plating for permanent fixation.
Figure 5. Preoperative X-ray of a 60-year-old woman.
Figure 6. Fracture healing at 3-month postoperative follow-up.
Table 1.Comparison of patient information between the experimental and control groups
Groups
n
Gender
Age
(years)
ASA
Male Female I II III
Experimental 18 11 7 51.1±7.3 6 10 2
Control 22 13 9 51.5±6.6 8 11 3
Statistics -
0.017
0.265
0.135
Pvalues -
0.897
0.610
0.935
ASA: American Society of Anesthesiologists.
Table 2.Comparison of the experimental and control groups postoperatively
Groups
n
Union time (m.)
VAS
SF-36
Range of shoulder motion postoperatively
0 1 2 3 4 5 Active flexion Extension Internal rotation External rotation Abduction
Experimental 18 4.7±1.6 1 16 1 0 0 0 88.0±5.7 148.0±18.6 49.0±2.2 45.0±5.6 64.0±9.2 138.0±28.8
Control 22 6.0±1.6 1 0 9 10 0 2 69.5±9. 5 121.7±17.2 42.1±2.1 35.0±3.6 52.1±5.7 106.0±15.7
Statistics - -2.558
-6.459
7.655 4.634 9.708 6.561 4.779 4.768
Pvalues - 0.015
0.001
0.001 0.001 0.001 0.001 <0.001 <0.001
VAS: visual analogue scale; m.: months; SF-36: Short Form (36) Health Survey.