Which additional augmented fixation procedure decreases surgical failure after proximal humeral fracture with medial comminution: fibular allograft or inferomedial screws?

Abstract

Background: The purpose of this study was to compare clinical and radiologic results between treatment with locking plate fixation and fibular allograft augmentation (FA) and treatment with locking plate fixation and additional inferomedial screws (IMSs) in 3- or 4-part proximal humeral fractures with medial comminution in geriatric patients. Methods: We enrolled 164 patients with 3- or 4-part proximal humeral fractures with medial comminution who were treated with locking plates. The patients were divided into 2 groups according to additional augmented fixation procedures. The IMS group was composed of patients treated with additional IMSs (80 patients), whereas the FA group was treated with an additional fibular allograft (84 patients). On the basis of fracture classification, the IMS group was subdivided into those with 3-part fractures (52 patients) and those with 4-part fractures (28 patients) and the FA group was subdivided into those with 3-part fractures (55 patients) and those with 4-part fractures (29 patients). Clinical and radiographic results were compared and analyzed. Results: In patients with 3-part fractures, no differences in clinical outcomes were found regardless of additional procedures. However. the PA group showed superior clinical outcomes in patients with 4-part fractures (P = .038 for Constant score and P= .045 for visual analog scale score). The postoperative neck-shaft angle was maintained in the FA group compared with the IMS group with both fracture types at the last follow-up (P = .048 for IMS vs FA with 3-part fractures and P= .023 for IMS vs FA with 4-part fractures). The number of complications was significantly higher in the IMS group (5.5%) than in the FA group (1.2%) (P = .001). Conclusion: An FA technique is considered a primary additional procedure for medial support in patients with 4-part proximal humeral fractures involving medial metaphyseal comminution when treated with locking plate fixation. (C) 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.