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Calcar screw position in proximal humerus fracture fixation: Don't miss high!

作者信息

Mehta Samir, Chin Matthew, Sanville Jennifer, Namdari Surena, Hast Michael W

机构信息

Biedermann Lab for Orthopaedic Research, University of Pennsylvania, Department of Orthopaedic Surgery, Philadelphia, PA, United States.

Rothman Institute, Thomas Jefferson University, Department of Orthopaedic Surgery, Philadelphia, PA, United States.

出版信息

Injury. 2018 Mar;49(3):624-629. doi: 10.1016/j.injury.2018.02.007. Epub 2018 Feb 11.


DOI:10.1016/j.injury.2018.02.007
PMID:29452734
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7413303/
Abstract

INTRODUCTION: In locked plate fixation of proximal humerus fractures, the calcar is an important anchor point for screws providing much-needed medial column support. Most locking plate implants utilize a fixed-trajectory locking screw to achieve this goal. Consequently, adjustments of plate location to account for patient-specific anatomy may result in a screw position outside of the calcar. To date, little is known about the consequences of "missing" the calcar during plate positioning. This study sought to characterize the biomechanics associated with proximal and distal placement of locking plates in a two-part fracture model. MATERIALS AND METHODS: This experiment was performed twice, first with elderly cadaveric specimens and again with osteoporotic sawbones. Two-part fractures were simulated and specimens were divided to represent proximal, neutral, and distal plate placements. Non-destructive torsional and axial compression tests were performed prior to an axial fatigue test and a ramp to failure. Torsional stiffness, axial stiffness, humeral head displacement and stiffness during fatigue testing, and ultimate load were compared between groups. RESULTS: Cadavers: Proximal implant placement led to trends of decreased mechanical properties, but there were no significant differences found between groups. Sawbones: Distal placement increased torsional stiffness in both directions (p = 0.003, p = 0.034) and axial stiffness (p = 0.018) when compared to proximal placement. Distal placement also increased torsional stiffness in external rotation (p = 0.020), increased axial stiffness (p = 0.024), decreased humeral head displacement during fatigue testing, and increased stiffness during fatigue testing when compared to neutral placement. DISCUSSION: The distal and neutral groups had similar mechanical properties in many cadaveric comparisons while the proximal group trended towards decreased construct stiffness. RESULTS: from the Sawbones model were more definitive and provided further evidence that proximal calcar screw placements are undesirable and distal implant placement may provide improved construct stability. CONCLUSION: Successful proximal humerus fracture reconstruction is inherent upon anatomic fracture reduction coupled with medial column support. Results from this experiment suggest that missing the calcar proximally is deleterious to fixation strength, while it is safe, and perhaps even desirable, to aim slightly distal to the intended target.

摘要

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本文引用的文献

[1]
Defining optimal calcar screw positioning in proximal humerus fracture fixation.

J Shoulder Elbow Surg. 2017-7-5

[2]
Locking Cap Designs Improve Fatigue Properties of Polyaxial Screws in Upper Extremity Applications.

J Orthop Trauma. 2017-5

[3]
Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures.

J Bone Joint Surg Am. 2016-11-2

[4]
The biomechanical cost of variable angle locking screws.

Injury. 2016-8

[5]
Additional calcar support using a blade device reduces secondary varus displacement following reconstruction of the proximal humerus: a prospective study.

Eur J Med Res. 2015-10-7

[6]
Biomechanical effect of medial cortical support and medial screw support on locking plate fixation in proximal humeral fractures with a medial gap: a finite element analysis.

Acta Orthop Traumatol Turc. 2015

[7]
Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures.

Clin Biomech (Bristol). 2014-8

[8]
Effect of Calcar Screw Use in Surgical Neck Fractures of the Proximal Humerus With Unstable Medial Support: A Biomechanical Study.

J Orthop Trauma. 2014-8

[9]
Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus.

J Shoulder Elbow Surg. 2014-2-16

[10]
Position of polyaxial versus monoaxial screws in locked plating for proximal humeral fractures: analysis of a prospective randomized study.

Eur J Orthop Surg Traumatol. 2014-7

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