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Review

Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures—A Single-Center Experience and Literature Review

by
Chun-Chi Peng
1,2,†,
Ting-Han Tai
1,† and
Chih-Yu Chen
1,3,*
1
Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 23561, Taiwan
2
Division of General Medicine, Department of Medical Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
3
International Ph.D. Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
J. Clin. Med. 2024, 13(17), 5109; https://doi.org/10.3390/jcm13175109
Submission received: 4 July 2024 / Revised: 15 August 2024 / Accepted: 20 August 2024 / Published: 28 August 2024
(This article belongs to the Section Orthopedics)
Browse Figure
Versions Notes

Abstract

:
Proximal humerus fractures (PHFs) are among the most common upper-extremity fractures, with a rising incidence linked to the growing elderly population. Treatment options include non-surgical and surgical methods, but the best approach for geriatric PHFs remains debated. Patient selection for treatment must consider clinical and functional outcomes and the potential complications of surgery. Osteoporosis, a key factor in elderly PHFs, meaning those in patients over 65 years old, often results from low-energy trauma and necessitates treatments that enhance bone healing. Bone cement, such as calcium phosphate, is widely used to improve fracture stability and healing. However, the benefits of surgical fixation with bone cement augmentation (BCA) for elderly PHF patients remain controversial. Hence, in this article, we searched databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science to analyze the evidence on locking plate fixation (LPF) with BCA for proximal humeral fractures. We aim to provide readers with updates concerning the above issues.

1. Introduction

Proximal humerus fractures (PHFs) are one of the most common types of upper-extremity fractures [1], accounting for about a third of upper-extremity fractures among the elderly population [2]. The prevalence of this kind of fracture increases with age and is more common in women, which could be linked to the higher incidence of osteoporosis in older women [3]. In fact, PHFs make up 18% of fractures in elderly patients with osteoporosis [4], and a 10% increase in PHF has been reported over the last decade [5]. However, whether geriatric patients should undergo surgical treatment still remains controversial. A multicenter randomized control trial compared operative and non-operative treatment for displaced two-part PHF; displacement was defined by Neer classification (displacement of more than 1 cm or 45 degrees, with bony contact) in patients 60 years of age or older, and no significant difference in clinical outcomes was found between the two groups [6]. On the other hand, Cosic et al. compared non-surgical and surgical treatment for PHF with 100% translation and demonstrated that operative management could result in better functional scores, fewer complications, and lower risk of non-union or malunion [7].
Various surgical treatments are available for treating PHF, including intramedullary nailing (IMN), percutaneous K-wire fixation, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA), but the majority of patients still undergo locking plate fixation (LPF) [8]. Locking plate fixation has been reported to achieve satisfactory results even in elderly patients [9,10], but was unable to provide improvement in Disabilities of the Arm, Shoulder, and Hand (DASH) score [6]. Furthermore, a high complication rate was reported in several previous studies, ranging from 15.4 to 59% [10,11,12,13]. Therefore, to cope with common complications such as screw cutout or varus malreduction, the usage of bone cement augmentation might be a reasonable choice for reinforcing LPFs and thus yielding better clinical outcomes.
Over the past decade, locking plate fixation (LPF) for proximal humerus fractures (PHFs) with bone cement augmentation has shown significant clinical benefits, including improved mid- to long-term outcomes, higher union rates, and reduced complication rates compared to non-cemented techniques [14,15,16,17,18]. Various bone cements, such as PMMA (polymethyl methacrylate) and calcium phosphate, offer distinct advantages. PMMA provides strong stability but increases the risk of avascular necrosis around the screw tip [17,18,19,20]. In contrast, calcium phosphate cement avoids thermal injury, promotes osteoconductivity, and remodels gradually [21,22,23]. Overall, bone cement augmentation in LPF is particularly beneficial for elderly patients with osteoporosis, enhancing fracture stability and minimizing complications. Furthermore, biomechanical studies by Schöbel et al. and Kennedy et al. suggest that bone cement augmentation, particularly with calcium phosphate-based cements, enhances primary stability in locking plate fixation for proximal humeral fractures, potentially reducing intra-fragmentary motion and improving fixation strength [23,24,25].
In the present review, we reviewed the latest evidence in terms of current concepts of management and the use of locking plate fixation with bone cement augmentation for elderly PHFs. Databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science were searched for the related literature using different combinations of keywords including elderly, geriatric, proximal humerus fractures, complication, osteoporosis, bone cement, augmentation, and calcium phosphate. The two co-first authors then independently screened the titles and abstracts of potentially related literature and identified articles within the scope of this review. In addition, we share our clinical insights and suggested potential areas for future research related to geriatric PHFs. Our goal is for this article to offer readers a thorough and current overview of PHFs in the elderly population.

2. Management of Elderly PHFs

Treatment methods for PHFs can be divided into non-operative and operative treatments. However, there is still some controversy and discussion regarding which method should be used. Below is an analysis of these two treatment approaches.

2.1. Non-Operative Treatment

Non-surgical treatments include a standard sling, shoulder spica cast, hanging arm cast, and airplane splint. These methods are significantly less expensive compared to surgical treatment. Recent studies, such as that of Lapner et al., indicate that surgical treatment with either locked plates or HA results in similar functional scores and pain outcomes as non-operative treatment [26]. Launonen et al. found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced two-part fractures of the proximal humerus [6]. These studies suggest that non-surgical treatment for PHFs is as effective as surgical treatment and avoids post-surgical complications. However, non-surgical treatment also carries risks of non-union, malunion, and poor alignment [27].

2.2. Operative Treatment

According to the existing literature, operative treatment could provide a more effective reduction in pain [28] and may achieve a better coronal plane alignment at 3 months [29]. Likewise, Samborski et al. demonstrated that LPF led to decreased pain and improved passive ROM compared with non-operative treatment at 3 months [30]. Among several options of treatment for PHF, Klug et al. revealed that LPF was the most used procedure in 642,556 cases of PHF, accounting for 48.3% of all surgical treatment [8]. However, the suitable treatment of PHF is still debatable.
In a meta-analysis regarding surgical treatment of PHF, the clinical outcomes and range of motion in LPF were found to be superior to those in HA and comparable to those in IMN and RSA [31]. In treating two- to three-part PHF, both IMN and LPF led to high complication rates of 19% and 30%, respectively [32]. The main problem of IMN in three-part PHF is that the starting point is often compromised, so plate fixation may be feasible despite the high risk of screw cutout. With regard to more severe fractures, Launonen et al. compared non-operative LPF and HA for three- to four-part PHF in older patients (>60 years) and found no difference in DASH score, constant score, and OSS (Oxford shoulder score) upon between-group and within-group comparison [12]. Gadea et al. retrospectively compared IMN and LPF for four-part displaced PHF and found that when a medial hinge was present preoperatively, LPF should be recommended because it could lead to better functional outcomes [33]. In their study, the rate of complications including avascular necrosis (AVN) and screw penetration was comparable between IMN and LPF, but the revision rate was higher in the LPF (30%) than IMN (18.5%).
Locking plate fixation is effective in achieving good reduction and union rates in PHFs. However, it carries several risks and complications. According to a meta-analysis of 3422 cases, complications occurred at the following rates: intra-articular screw penetration (9.5%), varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), non-union (1.5%), and deep infection (1.4%) [34]. These complications tended to increase with the patient’s age and the complexity of the fracture [34,35,36,37,38]. Additionally, the presence of osteoporosis further exacerbates these risks. Studies have highlighted that older patients and those with more complex fractures are more susceptible to these adverse outcomes, emphasizing the need for careful consideration and management in such populations [39,40,41].
The indications for surgery in the treatment of PHFs and the type of surgery to be undertaken are still controversial and depend on the status of the patient and Neer’s classification. Although locking plate fixation is the most frequent modality of surgical intervention, studies have proven that LPF does not have lower rates of complications and variable functional outcomes under different circumstances. Hence, some research works have combined bone cement with LPF for maximum results to achieve skeletal stabilization and reduce the post-operative complications of bone cement.

2.3. Outcome

After the treatment of proximal humerus fractures, various outcomes and functional tools are used to assess the success of treatment and the recovery of the patient. In this context, the constant score tool is more predominantly used with a frequency of 65%. This is then followed by the DASH score in 31% of cases and the American Shoulder and Elbow Surgeons (ASES) score in 18% of cases (see Table 1) [42].
The constant score is the most commonly used overall scoring system; it evaluates shoulder function through pain, activities of daily living, range of motion, and power. The DASH score, however, is a patient-reported questionnaire that measures the extent of disability and symptoms in upper limb disorders. It brings together physician-assessed and patient-reported components to measure shoulder function.
A number of studies have revealed different predictors influencing the prognosis of proximal humerus fracture. These include age, sex, socioeconomic status, and the extent of the fracture. Other prognostic factors include surgical factors and operator skill. Moreover, factors such as general health, comorbidities, and adherence to rehabilitation protocols are all associated with the recovery and functional prognosis. This knowledge helps to form a treatment plan for each individual and delineates realistic expectations from the recovery process [43,44,45,46,47].
Table 1. Outcome functional measure tools commonly used to evaluate the effectiveness of PHF treatment.
Table 1. Outcome functional measure tools commonly used to evaluate the effectiveness of PHF treatment.
Outcome Functional Measure ToolsContent
Constant score [48,49]Requires both patient and physician participation to assess subjective and objective measurements including pain (15 points), activities of daily living (20 points), strength (25 points), and the range of motion such as forward elevation, external rotation, abduction and internal rotation of the shoulder (40 points), with a total of 100 points. The higher the score, the higher the quality of the function.
Disabilities of the Arm, Shoulder, and Hand (DASH) score [50]A patient-specific questionnaire containing 30 items including three main categories:
(1) difficulty in performing physical activities due to issues in the shoulder, arm, or hand (21 items);
(2) severity of symptoms like pain, tingling, weakness, and stiffness (5 items);
(3) the impact of these problems on social activities, work, sleep, and mental state (4 items).
Each item ranges from 1 (no difficulty in performing or no symptom) to 5 (unable to do or very severe symptom). The summed scores of the 30 items are converted to a 0-to-100 scale with the following formula: [(sum of score/n) − 1] × 25, where n is the number of completed responses, and a higher score indicates greater disability.
American Shoulder and Elbow Surgeons Shoulder (ASES) score [51]The ASES score can be viewed as a 100-point scale that evaluates two dimensions of shoulder function: pain and performance in activities of daily living (ADL). The ADL categories range from 0 (unable to do) to 3 (not difficult at all).
Oxford shoulder score (OSS) [52]Contains 12 items to be answered by the patient independently, focusing on pain and patients’ functionality in daily activities. There are five categories of response for every question, with a score from 1 to 5. The summed scores range from 12 (best) to 60 (worst).

3. LPF with Bone Cement Augmentation for Elderly PHFs

Recognizing that LPF alone often fails to achieve significantly better outcomes than conservative treatments, orthopedic surgeons are examining whether incorporating BCA can overcome the limitations associated with LPF. This section reviews the existing literature on the use of LPF with BCA for PHFs, especially in elderly patients. We also provide an overview of various types of bone cements. Our survey identifies several pertinent studies, including two meta-analyses [53] and three retrospective studies [54,55,56], whose main findings and appraisals are summarized herein.

3.1. Bone Cement Augmentation for Locking Plate Fixation

In the past decade, plate fixation with cement augmentation has been initiated and claimed to provide excellent clinical results in treating PHFs. The literature reports benefits from the use of different bone cements. Longo et al. conducted a meta-analysis comparing 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. The study included 19 studies; 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. Their findings suggest that locking plate fixation with cement augmentation resulted in a lower complication rate compared to locking plate fixation alone [53]. Another meta-analysis, which included a total of 541 patients, showed that cement augmentation may reduce overall complications primarily by preventing implant-related complications [57]. Gavaskar et al. injected calcium phosphate into the metaphyseal bone void after reduction in elderly patients with complex humeral fractures, reporting a 92% union rate [54]. Hristrov et al. used PMMA-based cement in three- and four-part PHF with good clinical results at 12 months, even in aged patients [58]. She et al. reported that a dedicated locking plate with cement-augmented screws showed good mid- to long-term results without complications such as humeral head necrosis or loosening of screws [14]. Cement augmentation in second-generation locked plating by Schuetze et al. showed reduced risks for complications and secondary dislocation [15]. Hakimi et al. showed that the rate of complications including loss of reduction and screw cutout was significantly lower with cement augmentation [16]. Foruria et al. and Siebenburger et al. both showed that elderly patients have a substantially lower rate of implant failure and a less frequent rate of loss of fixation using cement augmentation [17,18].
Comparing different types of bone cement, PMMA is used more frequently for its superior stability, yielding a low rate of displacement and loss of fixation in elderly patients with poor bone quality [18,20]. However, it may increase the risk of avascular necrosis around the screw tip, with incidence ranging from 3.8% to 16.7% [17,18,20]. On the other hand, calcium phosphate bone cement (CPBC) prevents thermal injury, promotes osteoconductivity, and gradually remodels. It mimics the mineral phase of bone, with compressive strength greater than normal cancellous bone [21], and therefore reduces stress, improving the stability between the implant and proximal humerus. Experience-based studies by Gavaskar et al., Kennedy et al., and Schöbel et al. [22,23,54] also show equivalent or even better results for CPBC. This reabsorption of the CPBC within six months to 10 years minimizes potential damage due to intra-articular cement leakage [59]. In brief, bone cement augmentation in plate fixation for PHF enhances stability. It reduces complications, especially in elderly patients with osteoporosis, by using the inherent benefits of different bone cements.
There are three related retrospective studies articles discussing the comparison of PHFs with or without calcium phosphate bone cement augmentation (CPBCA) (see Table 2). Egol et al. reviewed 92 patients who received a dedicated locking plate for PHFs, with 27 of them using calcium phosphate cement for augmentation. In comparison to the allograft cancellous chip augmentation group (n = 29) and the non-augmented group (n = 36), CPBCA demonstrated a significantly lower screw penetration rate [56]. However, the author did not record the patient-reported outcome. Knapp et al. compared bone defects augmented with CPBCA with those with empty defects (EDs) in humerus, radius and tibia fractures, including 11 PHFs treated with osteosynthesis with CPBCA and 11 treated with osteosynthesis alone [55]. The results indicated fewer complications in the CPBCA group relative to the ED group, which was also the case in geriatric patients. Though they did not conduct a head-to-head comparison between the case with PHF, the study still demonstrated the benefits of accelerating osseous healing and lowering post-operative complications with the application of CPBCA.
Table 2. Studies investigating the effectiveness of LPF with or without BCA for PHFs.
Table 2. Studies investigating the effectiveness of LPF with or without BCA for PHFs.
StudyStudy TypeSubjectInterventionComparatorOutcome MeasurementsMain ResultsConclusion
Knapp et al. [55]Retrospective cohort22 proximal humerus fracture
(mean age: 55.44 years)		osteosynthesis with CPBCA
(n = 11)		osteosynthesis alone
(n = 11)		Complications; Radiographics;
Fracture edge;
Fracture gap;
Articular surface		CPBCA group significantly reduces post-operative complications, including pseudarthrosis, post-traumatic arthrosis, and neurological diseases, compared to non-augmented treatments.CPBCA have proven their clinical integrity by demonstrating safety in medical applications. They support an accelerated early bone healing process and reduce the severity of complications within the group of patients treated with these substitutes.
Egol et al. [56]Retrospective cohort92 acute traumatic proximal fracture
(mean age: 61 years)		LPF with CPBCA
(n = 27)		Cancellous chips
(n = 29);
no augmentation
(n = 36)		Complications;
Intra-articular penetration;
Humeral head settling		CPBCA in LPF reduces humeral head settling and joint penetration compared to non-augmented repairs or repairs with cancellous chips.CPBCA in the treatment of PHFs with LPF decreased fracture settling and significantly decreased intra-articular screw penetration.
Gavaskar et al. [54]Retrospective cohort29 displaced 3- to 4-part complex humeral fracture
(mean age: 79 years)		Subchondral metaphyseal bone voids were filled with injectable CPBCA
(n = 29)		nilRadiological outcomes; Functional outcomes; ComplicationsIn a follow-up of 26 patients over an average of 27 months, fractures united in 24, while 3 required arthroplasty due to complications. Functional improvement was shown by age-adjusted Constant (63.1 ± 11.9) and ASES (62.58 ± 7.5) scores.Osteosynthesis with second generation locked plating techniques provide satisfactory outcomes in very elderly patients with complex PHFs with minimal complications.
LPF: locking plate fixation, BCA: bone cement augmentation, PHFs: proximal humeral factures, CPBCA: calcium phosphate bone cement augmentation.

3.2. Our Experiences

In our hospital, we retrospectively analyzed all the elderly patients over 65 years who had presented with a proximal humeral fracture due to low-energy injury. These patients were subsequently treated using the Biomet A.L.P.S. Proximal Humeral Plating System® (Zimmer Biomet, Warsaw, IN, USA) reinforced with CPBCA (Pro-Dense®, Wright Medical Technology™, Arlington, TN, USA) between May 2023 and December 2023. Patients with debilitating pre-existing comorbidities, ipsilateral upper extremity injury, previous shoulder injury, delay in surgery of >two weeks, or who received <1 mL injected CPBCA were not included in this analysis. These exclusion criteria were used for the sake of homogeneity and result reliability.
With the application of these criteria, eight patients under 65 years of age and three patients who presented with only surgical neck fractures were excluded. This led to a group of 20 patients for the analysis: 6 men with an average age of 74.5 years (age range: from 66 to 88) and 14 women with an average age of 86.6 years (age range: from 82 to 94). No intraoperative complications occurred during surgery, showing a high level of safety in the procedure. Immediate post-surgical radiographs revealed 16 patients to have anatomic reduction, whereas the rest had near-anatomic reduction. This implies that surgical interventions managed to restore the anatomical alignment of the fractured humerus.
In no case was fixation failure, screw cut-through, or loss of fixation observed at both the 3-month and 6-month post-surgical follow-ups. This represents a valuable finding in establishing the stability and effectiveness of the combined treatment approach. The mean VAS scores, being explanatory measures of pain levels, were very low and amounted to 1.66 with a range of 0 to 6 at 3 months and 0.42 with a range of 0 to 4 at 6 months. These low scores reflect success in the pain management and recovery of the patient. No patient reported decreased shoulder motion or functional interference in daily life, which would suggest that no patient suffered from limited shoulder mobility. Three patients, however, developed minor secondary plate/screw displacement due to a fracture site compression. Even so, none of these needed surgical revision (see Table 3).
No post-operative complications, such as non-union or surgical site infection, were seen in the follow-up period. This confirms the safety and effectiveness of the treatment protocol followed. The follow-up radiological assessment showed great improvement in the diameter of the humeral head, position of the greater tuberosity, and the neck–shaft angle for each patient when compared to the first post-surgical radiograph. These changes are indicative of anatomical and functional recovery in the patients.
The seniors have more prevalence of osteoporosis and are vulnerable to comminuted PHFs; traditional LPF alone cannot stabilize the post-operative radial height and inclination in many patients, especially when severe osteoporosis and serious metaphyseal bone loss is considered. However, through experience, the CPBCA is much more biomechanically supportive and eradicates the chances of secondary collapse with promotion of bone healing. Moreover, it can be appreciated in Figure 1 that the configuration is better retained with less chance of loss of fixation, delayed union, or non-union in the application of CPBCA in the LPF. This combination treatment seems to have special benefits for the restoration of structure and function in elderly patients with PHF.

4. Summary

In conclusion, based on this review, conservative non-surgical treatments have clinical and functional outcomes similar to those of surgical treatments with complication rates for elderly patients with proximal humerus fractures. However, the surgical treatments, including LPF, can achieve better anatomical reconstruction, reduce pain effectively, and improve passive range of motion compared with non-operative approaches in these appropriately selected elderly and super-elderly patients. Although LPF is one of the most common methods for the treatment of PHFs, the best surgical approach varies with individual patient characteristics.
With regard to post-operative outcomes, several complications are associated with LPF, such as intra-articular screw penetration, varus collapse, subacromial impingement, avascular necrosis, adhesive capsulitis, non-union, and deep infection. The major cause for all these complications is osteoporosis. LPF with BCA is much more beneficial for the elderly with osteoporosis as it increases the stability of the fracture and decreases complications. Clinical outcomes indicate that patients treated with this combination experience quicker recovery times and improved range of motion in the affected limb. The addition of CPBCA adds stability and enables early mobilization, thereby considerably shortening the overall rehabilitation period. The method also reduces the risk of post-operative complications, thus increasing the quality of life of patients during the phase of recovery. The evidence suggests that this innovative approach could set a new standard in the treatment of complex fractures in osteoporotic patients. Therefore, we do recommend detailed assessment of the individual condition of all elderly patients before initiating LPF with BCA.
However, since there is variation in most studies as to the type of bone cement used, additional RCTs with a larger sample size are necessary to confirm this beneficial effect of LPF with BCA in elderly PHFs. A subgroup analysis should also be conducted to tease out populations that specifically benefit more from LPF with BCA with respect to factors such as age, gender, activity levels, comorbidities like osteoporosis, and Neer classification. Further studies need to be conducted on the comparative effectiveness of surgical compared with conservative treatment in elderly patients with PHFs in terms of risks and outcomes in a more comprehensive way, integrating the relevant risk and predictive factors of optimizing resource allocations in keeping with patient preferences and expectations.
A few limitations of our review need to be mentioned. First, although we tried to write an up-to-date review on this topic, some of the studies may already have been published after the search time concluded. Second, due to the paucity of and heterogeneous research designs in studies, we cannot currently make a firm recommendation on LPF with BCA for elderly PHFs. Nevertheless, based on our clinical experiences, LPF with BCA seems effective and safe.
Therefore, LPF with BCA might provide better short-term and long-term results than non-surgical management for elderly patients with PHFs. More research in this area will be indispensable in determining the precise efficacy of LPF with BCA, developing improved assessment tools, and validating procedural approaches to treating elderly patients with PHFs.

Author Contributions

Conceptualization, C.-C.P. and T.-H.T.; methodology, C.-C.P. and T.-H.T.; validation, T.-H.T.; investigation, C.-C.P. and T.-H.T.; resources, T.-H.T. and C.-Y.C.; writing—original draft preparation, C.-C.P. and T.-H.T.; writing—review and editing, C.-Y.C.; supervision, C.-Y.C.; project administration, C.-Y.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Iglesias-Rodríguez, S.; Domínguez-Prado, D.M.; García-Reza, A. Epidemiology of proximal humerus fractures. J. Orthop. Surg. Res. 2021, 16, 402. [Google Scholar] [CrossRef] [PubMed]
  2. Lübbeke, A.; Stern, R.; Grab, B.; Herrmann, F.; Michel, J.P.; Hoffmeyer, P. Upper extremity fractures in the elderly: Consequences on utilization of rehabilitation care. Aging Clin. Exp. Res. 2005, 17, 276–280. [Google Scholar] [CrossRef]
  3. Walter, N.; Szymski, D.; Kurtz, S.M.; Lowenberg, D.W.; Alt, V.; Lau, E.; Rupp, M. Proximal humerus fractures—Epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data. Bone Jt. Res. 2023, 12, 103–112. [Google Scholar] [CrossRef]
  4. Yang, Z.; Xing, D.; Dong, Z.; Wei, J.; Zhang, L.; Gao, S.; Li, W. Epidemiological Investigation of 387 Individuals over 65 Years Old with Osteoporotic Fractures. Altern. Ther. Health Med. 2023, 29, 207–211. [Google Scholar]
  5. Rupp, M.; Walter, N.; Pfeifer, C.; Lang, S.; Kerschbaum, M.; Krutsch, W.; Baumann, F.; Alt, V. The Incidence of Fractures among the Adult Population of Germany—An Analysis from 2009 through 2019. Dtsch. Arztebl. Int. 2021, 118, 665–669. [Google Scholar]
  6. Launonen, A.P.; Sumrein, B.O.; Reito, A.; Lepola, V.; Paloneva, J.; Jonsson, K.B.; Wolf, O.; Ström, P.; Berg, H.E.; Felländer-Tsai, L.; et al. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019, 16, e1002855. [Google Scholar] [CrossRef]
  7. Cosic, F.; Kirzner, N.; Edwards, E.; Page, R.; Kimmel, L.; Gabbe, B. The Translated Proximal Humerus Fracture: A Comparison of Operative and Nonoperative Management. J. Orthop. Trauma 2023, 37, e341–e348. [Google Scholar] [CrossRef]
  8. Klug, A.; Gramlich, Y.; Wincheringer, D.; Schmidt-Horlohé, K.; Hoffmann, R. Trends in surgical management of proximal humeral fractures in adults: A nationwide study of records in Germany from 2007 to 2016. Arch. Orthop. Trauma Surg. 2019, 139, 1713–1721. [Google Scholar] [CrossRef]
  9. Descalzo Godoy, I.; Velasco Alcalde, P.; Del Olmo Galeano, A.; Del Río Hortelano, J.; Martínez Velez, D.; Fernández González, J. Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70 years: A retrospective cohort study. Eur. J. Orthop. Surg. Traumatol. 2024, 34, 415–423. [Google Scholar] [CrossRef]
  10. Vijayvargiya, M.; Pathak, A.; Gaur, S. Outcome Analysis of Locking Plate Fixation in Proximal Humerus Fracture. J. Clin. Diagn. Res. 2016, 10, Rc01–Rc05. [Google Scholar] [CrossRef]
  11. Barlow, J.D.; Logli, A.L.; Steinmann, S.P.; Sems, S.A.; Cross, W.W.; Yuan, B.J.; Torchia, M.E.; Sanchez-Sotelo, J. Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate. J. Shoulder Elb. Surg. 2020, 29, 1689–1694. [Google Scholar] [CrossRef]
  12. Launonen, A.P.; Sumrein, B.O.; Reito, A.; Lepola, V.; Paloneva, J.; Berg, H.E.; Felländer-Tsai, L.; Kask, K.; Rahnel, T.; Tootsi, K.; et al. Surgery with locking plate or hemiarthroplasty versus nonoperative treatmeof 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial. PLoS Med. 2023, 20, e1004308. [Google Scholar] [CrossRef] [PubMed]
  13. Schliemann, B.; Siemoneit, J.; Theisen Ch Kösters, C.; Weimann, A.; Raschke, M.J. Complex fractures of the proximal humerus in the elderly--outcome and complications after locking plate fixation. Musculoskelet. Surg. 2012, 96 (Suppl. S1), S3–S11. [Google Scholar] [CrossRef] [PubMed]
  14. She, R.; Zhang, B.; Jiang, K.; Yang, S.; Zhang, Y. Cement-Augmented Screw Fixation with PHILOS Plating for Osteoporotic Proximal Humeral Fractures: An Observation of Mid- and Long-Term Curative Efficacy. Orthop. Surg. 2023, 15, 3108–3117. [Google Scholar] [CrossRef] [PubMed]
  15. Schuetze, K.; Boehringer, A.; Cintean, R.; Gebhard, F.; Pankratz, C.; Richter, P.H.; Schneider, M.; Eickhoff, A.M. Feasibility and Radiological Outcome of Minimally Invasive Locked Plating of Proximal Humeral Fractures in Geriatric Patients. J. Clin. Med. 2022, 11, 6751. [Google Scholar] [CrossRef]
  16. Hakimi, S.A.; Schumacher, K.; Ring, A. Angle-stable polyaxial locked plating with and without polymethylmethacrylate cement augmentation for proximal humeral fractures in elderly. Jt. Dis. Relat. Surg. 2021, 32, 575–582. [Google Scholar] [CrossRef]
  17. Foruria, A.M.; Martinez-Catalan, N.; Valencia, M.; Morcillo, D.; Calvo, E. Proximal humeral fracture locking plate fixation with anatomic reduction, and a short-and-cemented-screws configuration, dramatically reduces the implant related failure rate in elderly patients. JSES Int. 2021, 5, 992–1000. [Google Scholar] [CrossRef]
  18. Siebenbürger, G.; Helfen, T.; Biermann, N.; Haasters, F.; Böcker, W.; Ockert, B. Screw-tip augmentation versus standard locked plating of displaced proximal humeral fractures: A retrospective comparative cohort study. J. Shoulder Elb. Surg. 2019, 28, 1326–1333. [Google Scholar] [CrossRef]
  19. Hengg, C.; Nijs, S.; Klopfer, T.; Jaeger, M.; Platz, A.; Pohlemann, T.; Babst, R.; Franke, J.; Kralinger, F. Cement augmentation of the proximal humerus internal locking system in elderly patients: A multicenter randomized controlled trial. Arch. Orthop. Trauma Surg. 2019, 139, 927–942. [Google Scholar] [CrossRef]
  20. Knierzinger, D.; Crepaz-Eger, U.; Hengg, C.; Kralinger, F. Does cement augmentation of the screws in angular stable plating for proximal humerus fractures influence the radiological outcome: A retrospective assessment. Arch. Orthop. Trauma Surg. 2020, 140, 1413–1421. [Google Scholar] [CrossRef]
  21. Kammerlander, C.; Neuerburg, C.; Verlaan, J.J.; Schmoelz, W.; Miclau, T.; Larsson, S. The use of augmentation techniques in osteoporotic fracture fixation. Injury 2016, 47 (Suppl. S2), S36–S43. [Google Scholar] [CrossRef] [PubMed]
  22. Kennedy, J.; Feerick, E.; McGarry, P.; FitzPatrick, D.; Mullett, H. Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: A finite element analysis. J. Orthop. Surg. 2013, 21, 167–172. [Google Scholar] [CrossRef] [PubMed]
  23. Schöbel, T.; Schleifenbaum, S.; Nitsch, V.; Hepp, P.; Theopold, J. Primary stability of cement augmentation in locking plate fixation for proximal humeral fractures: A comparison of absorbable versus non-absorbable cement. Clin. Biomech. 2022, 91, 105516. [Google Scholar] [CrossRef] [PubMed]
  24. Kennedy, J.; Molony, D.; Burke, N.G.; FitzPatrick, D.; Mullett, H. Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: A cadaveric biomechanical study. J. Orthop. Surg. 2013, 21, 173–177. [Google Scholar] [CrossRef] [PubMed]
  25. Gradl, G.; Knobe, M.; Stoffel, M.; Prescher, A.; Dirrichs, T.; Pape, H.C. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J. Orthop. Trauma 2013, 27, 399–404. [Google Scholar] [CrossRef]
  26. Lapner, P.; Sheth, U.; Nam, D.; Schemitsch, E.; Guy, P.; Richards, R.; Canadian Shoulder and Elbow Society (CSES); Canadian Orthopedic Trauma Society (COTS). Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis. J. Orthop. Trauma 2023, 37, e80–e88. [Google Scholar] [CrossRef]
  27. Martinez-Catalan, N. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. Curr. Rev. Musculoskelet. Med. 2023, 16, 75–84. [Google Scholar] [CrossRef]
  28. Rabi, S.; Evaniew, N.; Sprague, S.A.; Bhandari, M.; Slobogean, G.P. Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials. World J. Orthop. 2015, 6, 838–846. [Google Scholar] [CrossRef]
  29. Hauschild, O.; Konrad, G.; Audige, L.; De Boer, P.; Lambert, S.M.; Hertel, R.; Südkamp, N.P. Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch. Orthop. Trauma Surg. 2013, 133, 1385–1393. [Google Scholar] [CrossRef]
  30. Samborski, S.A.; Haws, B.E.; Karnyski, S.; Soles, G.; Gorczyca, J.T.; Nicandri, G.; Voloshin, I.; Ketz, J.P. Early Outcomes of Proximal Humerus Fractures in Adults Treated with Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis. J. Orthop. Trauma 2023, 37, 142–148. [Google Scholar] [CrossRef]
  31. Hohmann, E.; Keough, N.; Glatt, V.; Tetsworth, K. Surgical treatment of proximal humerus fractures: A systematic review and meta-analysis. Eur. J. Orthop. Surg. Traumatol. 2023, 33, 2215–2242. [Google Scholar] [CrossRef] [PubMed]
  32. Pandey, R.; Raval, P.; Manibanakar, N.; Nanjayan, S.; McDonald, C.; Singh, H. Proximal humerus fractures: A review of current practice. J. Clin. Orthop. Trauma 2023, 43, 102233. [Google Scholar] [CrossRef]
  33. Gadea, F.; Favard, L.; Boileau, P.; Cuny, C.; d’Ollone, T.; Saragaglia, D.; Sirveaux, F.; SOFCOT. Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases. Orthop. Traumatol. Surg. Res. 2016, 102, 963–970. [Google Scholar] [CrossRef]
  34. Kavuri, V.; Bowden, B.; Kumar, N.; Cerynik, D. Complications Associated with Locking Plate of Proximal Humerus Fractures. Indian J. Orthop. 2018, 52, 108–116. [Google Scholar] [CrossRef]
  35. Jost, B.; Spross, C.; Grehn, H.; Gerber, C. Locking plate fixation of fractures of the proximal humerus: Analysis of complications, revision strategies and outcome. J. Shoulder Elb. Surg. 2013, 22, 542–549. [Google Scholar] [CrossRef]
  36. Sun, Q.; Wu, X.; Wang, L.; Cai, M. The plate fixation strategy of complex proximal humeral fractures. Int. Orthop. 2020, 44, 1785–1795. [Google Scholar] [CrossRef]
  37. Bai, L.; Fu, Z.G.; Wang, T.B.; Chen, J.H.; Zhang, P.X.; Zhang, D.Y.; Jiang, B.G. Radiological evaluation of reduction loss in unstable proximal humeral fractures treated with locking plates. Orthop. Traumatol. Surg. Res. 2014, 100, 271–274. [Google Scholar] [CrossRef]
  38. Oldrini, L.M.; Feltri, P.; Albanese, J.; Marbach, F.; Filardo, G.; Candrian, C. PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis. Life 2022, 12, 311. [Google Scholar] [CrossRef]
  39. Klug, A.; Wincheringer, D.; Harth, J.; Schmidt-Horlohé, K.; Hoffmann, R.; Gramlich, Y. Complications after surgical treatment of proximal humerus fractures in the elderly-an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating. J. Shoulder Elb. Surg. 2019, 28, 1674–1684. [Google Scholar] [CrossRef]
  40. Carbone, S.; Papalia, M. The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation. Osteoporos. Int. 2016, 27, 627–633. [Google Scholar] [CrossRef]
  41. Jung, S.W.; Shim, S.B.; Kim, H.M.; Lee, J.H.; Lim, H.S. Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery. J. Orthop. Trauma 2015, 29, 276–282. [Google Scholar] [CrossRef]
  42. Richard, G.J.; Denard, P.J.; Kaar, S.G.; Bohsali, K.I.; Horneff, J.G.; Carpenter, S.; Fedorka, C.J.; Mamelson, K.; Garrigues, G.E.; Namdari, S. Outcome measures reported for the management of proximal humeral fractures: A systematic review. J. Shoulder Elb. Surg. 2020, 29, 2175–2184. [Google Scholar] [CrossRef] [PubMed]
  43. Hardeman, F.; Bollars, P.; Donnelly, M.; Bellemans, J.; Nijs, S. Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury 2012, 43, 153–158. [Google Scholar] [CrossRef] [PubMed]
  44. Gavaskar, A.S.; Pattabiraman, K.; Srinivasan, P.; Raj, R.V.; Jayakumar, B.; Rangasamy, N.K. What Factors Are Associated with Poor Shoulder Function and Serious Complications after Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations? Clin. Orthop. Relat. Res. 2022, 480, 1566–1573. [Google Scholar] [CrossRef] [PubMed]
  45. Jung, S.W.; Jeon, J.M.; Lee, C.H. Characteristics and Functional Outcomes of Varus Displaced Proximal Humerus Fractures. J. Orthop. Sci. 2024, in press. [Google Scholar] [CrossRef]
  46. Kantharaju, H.; Gawhale, S.K.; Prasanna Kumar, G.S.; Sahare, B.; Shah, N. Factors Influencing the Varus Deformity of Humeral Head in Proximal Humerus Fractures and Its Relation to Functional Outcome. Indian J. Orthop. 2021, 55, 702–707. [Google Scholar] [CrossRef]
  47. Christiano, A.; Pean, C.A.; Konda, S.; Egol, K.A. Functional outcome after proximal humerus fracture fixation: Understanding the risk factors. Acta Orthop. Belg. 2017, 83, 1–7. [Google Scholar]
  48. Sproul, R.C.; Iyengar, J.J.; Devcic, Z.; Feeley, B.T. A systematic review of locking plate fixation of proximal humerus fractures. Injury 2011, 42, 408–413. [Google Scholar] [CrossRef]
  49. Ziegler, P.; Kühle, L.; Stöckle, U.; Wintermeyer, E.; Stollhof, L.E.; Ihle, C.; Bahrs, C. Evaluation of the Constant score: Which is the method to assess the objective strength? BMC Musculoskelet. Disord. 2019, 20, 403. [Google Scholar] [CrossRef]
  50. Franchignoni, F.; Vercelli, S.; Giordano, A.; Sartorio, F.; Bravini, E.; Ferriero, G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J. Orthop. Sports Phys. Ther. 2014, 44, 30–39. [Google Scholar] [CrossRef]
  51. Richards, R.R.; An, K.N.; Bigliani, L.U.; Friedman, R.J.; Gartsman, G.M.; Gristina, A.G.; Iannotti, J.P.; Mow, V.C.; Sidles, J.A.; Zuckerman, J.D. A standardized method for the assessment of shoulder function. J. Shoulder Elb. Surg. 1994, 3, 347–352. [Google Scholar] [CrossRef]
  52. Dawson, J.; Fitzpatrick, R.; Carr, A.; Murray, D. Questionnaire on the perceptions of patients about total hip replacement. J. Bone Jt. Surg. Br. 1996, 78, 185–190. [Google Scholar] [CrossRef]
  53. Longo, U.G.; Gulotta, L.V.; De Salvatore, S.; Lalli, A.; Bandini, B.; Giannarelli, D.; Denaro, V. Augmented versus non-augmented locking-plate fixation in proximal humeral fractures. Bone Jt. J. 2024, 106-B, 646–655. [Google Scholar] [CrossRef]
  54. Ashok, S.G.; Karthik, B.; Tummala, N.C.; Srinivasan, P.; Gopalan, H. Second generation locked plating for complex proximal humerus fractures in very elderly patients. Injury 2016, 47, 2534–2538. [Google Scholar]
  55. Knapp, G.; Pawelke, J.; Heiss, C.; Elmas, S.; Vinayahalingam, V.; ElKhassawna, T. Traumatic Fracture Treatment: Calcium Phosphate Bone Substitute Case-Control Study in Humerus, Radius, Tibia Fractures-Assessing Efficacy and Recovery Outcomes. Biomedicines 2023, 11, 2862. [Google Scholar] [CrossRef] [PubMed]
  56. Egol, K.A.; Sugi, M.T.; Ong, C.C.; Montero, N.; Davidovitch, R.; Zuckerman, J.D. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J. Shoulder Elb. Surg. 2012, 21, 741–748. [Google Scholar] [CrossRef] [PubMed]
  57. Lecoultre, Y.; Beeres, F.J.P.; Link, B.C.; Pretz, F.; Tillmann, F.; Babst, R.; van de Wall, B.J.M. Cement augmentation for proximal humerus fractures: A meta-analysis of randomized trials and observational studies. Eur. J. Trauma Emerg. Surg. 2024. [Google Scholar] [CrossRef] [PubMed]
  58. Hristov, S.; Visscher, L.; Winkler, J.; Zhelev, D.; Ivanov, S.; Veselinov, D.; Baltov, A.; Varga, P.; Berk, T.; Stoffel, K.; et al. A Novel Technique for Treatment of Metaphyseal Voids in Proximal Humerus Fractures in Elderly Patients. Medicina 2022, 58, 1424. [Google Scholar] [CrossRef]
  59. Ferguson, J.; Diefenbeck, M.; McNally, M. Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections. J. Bone Jt. Infect. 2017, 2, 38–51. [Google Scholar] [CrossRef]
Jcm 13 05109 g001
Figure 1. Comparison of LPF with (A1–A3) or without (B1–B3) CPBCA in elderly PHFs: Patient A: (A1) A left PHF was presented. (A2) Treated with LPF with CPBCA. (A3) Post-operative X-ray at 12 months follow-up; Patient B: (B1) A left PHF was presented. (B2) Treated with LPF without CPBCA. (B3) Post-operative X-ray at 12 months follow-up. By comparison, the patient managed with a combination of LPF and CPBCA fared better with a stable head of humerus, maintained neck–shaft angle, and position of greater tuberosity fragments; in patient B, who had LPF without CPBCA, the head of humerus had a progressive collapse, the neck–shaft angle was reduced, and greater tuberosity fragments were migrated (arrow).
Figure 1. Comparison of LPF with (A1–A3) or without (B1–B3) CPBCA in elderly PHFs: Patient A: (A1) A left PHF was presented. (A2) Treated with LPF with CPBCA. (A3) Post-operative X-ray at 12 months follow-up; Patient B: (B1) A left PHF was presented. (B2) Treated with LPF without CPBCA. (B3) Post-operative X-ray at 12 months follow-up. By comparison, the patient managed with a combination of LPF and CPBCA fared better with a stable head of humerus, maintained neck–shaft angle, and position of greater tuberosity fragments; in patient B, who had LPF without CPBCA, the head of humerus had a progressive collapse, the neck–shaft angle was reduced, and greater tuberosity fragments were migrated (arrow).
Jcm 13 05109 g001
Table 3. Elderly patients with PHFs assessed between May 2023 and December 2023.
Table 3. Elderly patients with PHFs assessed between May 2023 and December 2023.
Overall
No. of patients (male/female)20 (6/14)
Mean age at surgery (range), y74.5 (66–88)/86.6 (82–94)
VAS score (3 months post operation)1.66 (0 to 6)
VAS score (6 months post operation)0.42 (0 to 4)
Fixation failure0
Decreased range of motion0
Secondary plate/screw displacement3
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Peng, C.-C.; Tai, T.-H.; Chen, C.-Y. Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures—A Single-Center Experience and Literature Review. J. Clin. Med. 2024, 13, 5109. https://doi.org/10.3390/jcm13175109

AMA Style

Peng C-C, Tai T-H, Chen C-Y. Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures—A Single-Center Experience and Literature Review. Journal of Clinical Medicine. 2024; 13(17):5109. https://doi.org/10.3390/jcm13175109

Chicago/Turabian Style

Peng, Chun-Chi, Ting-Han Tai, and Chih-Yu Chen. 2024. "Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures—A Single-Center Experience and Literature Review" Journal of Clinical Medicine 13, no. 17: 5109. https://doi.org/10.3390/jcm13175109

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