Fibular Allograft Augmentation Research Articles

Effect of Fibular Allograft Augmentation in Medial Column Comminuted Proximal Humeral Fractures: A Randomized Controlled Trial.

Previous observational studies and meta-analyses have recommended augmentation with a fibular allograft (FA) during the treatment of proximal humeral fractures with locking plates (LPs). However, to our knowledge, randomized controlled trials comparing open reduction and internal fixation (ORIF) with and without FA have not been performed to date. This was a randomized controlled trial in which adults with a medial column comminuted proximal humeral fracture were randomly allocated to undergo ORIF with an LP (the LP group) or with an LP augmented with an FA (the FA group). Patients were followed for 24 months. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months after the surgical procedure. The secondary outcomes included the DASH score at other time points, shoulder function, pain score, satisfaction, complications, and changes in neck-shaft angle and humeral head height. From October 20, 2016, to December 24, 2019, 80 patients were randomized. There were 52 women (65%), and the mean patient age (and standard deviation) was 65 ± 14 years. Of the 80 patients, 39 were allocated to the FA group and 41 were allocated to the LP group. At the primary time point (12 months), the unadjusted mean between-group difference in DASH score was -1.2 (95% confidence interval [CI], -7.3 to 5.0; p = 0.71) favoring the FA group, and, with adjustment for smoking, alcohol drinking, and diabetes, the between-group difference was -1.4 (95% CI, -7.7 to 5.0; p = 0.67) favoring FA. No significant differences between the 2 groups were found among the secondary outcomes. No additional benefit was found for FA augmentation in treating medial column comminuted proximal humeral fractures. Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Improved outcomes for proximal humerus fracture open reduction internal fixation augmented with a fibular allograft in elderly patients: a systematic review and meta-analysis.

To date, no meta-analysis has been performed on the efficacy of fibular allograft augmentation for the management of proximal humerus fractures. The purpose of this study was to evaluate the radiographic and clinical outcomes of proximal humerus fractures treated with a locking compression plate (LCP) with or without fibular allograft augmentation. The Cochrane Database of Systematic Reviews, the Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, and SCOPUS were queried in June of 2021 for literature comparing the radiographic and clinical outcomes for patients with proximal humerus fractures that were treated with an LCP only or an LCP augmented with a fibular allograft. Data describing study design, level of evidence, demographic information, final follow-up, radiographic changes in humeral head height (HHH), radiographic changes in neck shaft angle (NSA), final American Shoulder and Elbow Surgeons (ASES) scores, final Constant-Murley scores, and major complications were collected. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS). A meta-analysis was performed using pooled weighted mean differences (WMD) to compare changes in HHH, NSA, final ASES and final Constant-Murley scores between the 2 groups; a pooled odds ratio (OR) was used to compare complications between the groups. Ten studies with a total of 802 patients were identified. There was a significant difference that favored patients augmented with a fibular allograft for change in HHH (WMD=-2.40; 95% confidence interval [CI], -2.49 to -2.31; P<.00001), change in NSA (WMD=-5.71; 95% CI, -6.69 to -4.72; P<.00001), final ASES scores (WMD=5.08; 95% CI, 3.69-6.48; P<.00001), and OR for developing a major complication (OR=0.37; 95% CI, 0.23-0.59; P<.0001). There was no significant difference in final Constant-Murley scores (WMD=3.36; 95% CI, -0.21 to 6.93; P=.06) or revision surgery rate (P=.182) between the 2 groups. The pooled WMD and prediction interval suggest that 95% of patients with proximal humerus fractures treated with an LCP augmented with a fibular allograft will have improved radiographic outcomes, improved ASES clinical outcome scores, and decreased odds of a major complication when compared with patients treated with an LCP alone. Limitations of this study include a relatively short average final follow-up time (<2 years) and a potential lack of standardization for radiographic outcomes among included studies.

Pedicle Screw Track Augmentation With Fibular Allograft for Significant Bone Loss in Revision Fixation.

Retrospective cohort study. To report the clinical and radiological outcomes for screw track augmentation with fibular allograft in revision of loose pedicle screws associated with significant bone loss along the screw track. Thirty consecutive patients, 18 men (60%) and 12 women (40%), with a mean age 52 years (range 34- 68). Fibular allograft was prepared by cutting it into longitudinal strips 50 mm in length. Three allograft struts were inserted into the screw track. Six mm tap used to tap between the 3 fibular struts. Eight- or 9-mm diameter, and 45 or 50 mm in length screw was then inserted. The clinical outcomes were assessed by means of the Oswestry Disability Index (ODI), and visual analog scale (VAS) for back and leg pain for clinical outcome. Computed tomography scan (CT) performed at 12 months postoperative visit to assess fibular graft incorporation along the pedicle screw track, any screw loosening and the interbody as well as posterolateral fusion. At a mean follow up of 29 months, there were statically significant improvement in the ODI and VAS for back and leg pain. CT scan obtained at last follow-up showed incorporation of fibular allograft and solid fusion in all patients except one. The fibular allograft augmentation of the pedicle screw track in revision of loose pedicle screws associated with significant bone loss is a viable option. It allows for biologic fixation at the screw-bone interface and has some key advantages when compared to currently available methods.

Locking Plate Combined With Endosteal Fibular Allograft Augmentation for Medial Column Comminuted Proximal Humeral Fracture.

The goal of this study was to evaluate the role of endosteal fibular allografts in the treatment of medial column comminuted proximal humerus fractures with a locking plate. The authors retrospectively analyzed the clinical outcomes of 63 patients (21 men and 42 women) who had proximal humerus fractures with a comminuted medial column and were treated at Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China, with a locking plate, either alone or in combination with a fibular strut allograft, between January 2013 and May 2017. Patients were divided into 2 groups: locking plate combined with fibular allograft (41 patients) and locking plate alone (22 patients). After an average follow-up of 16.3 months, all fractures were healed. Statistically significant differences were seen between the 2 groups in changes in the neck-shaft angle, humeral head height (P<.001), and overall incidence of complications (P<.05). However, no statistically significant difference was found in the Constant-Murley score. The use of a locking plate in combination with intramedullary fibular allograft augmentation can help to maintain reduction and reduce postoperative complications in the treatment of proximal humerus fractures that are complicated by medial column comminution. [Orthopedics. 2020;43(6):367-372.].

Use of a locking intramedullary nail for the treatment of initial varus proximal humeral fracture: a prospective pilot study.

ObjectiveTo evaluate the feasibility of locked intramedullary nailing, rather than locking plate fixation combined with fibular allograft augmentation, for initial varus proximal humeral fractures.MethodsThis prospective pilot study enrolled patients with initial varus proximal humeral fractures that were treated with a locking intramedullary nail. Radiography was performed to evaluate fracture healing. Data about the visual analogue scale (VAS) pain score, Constant Shoulder Score (CSS), Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score and shoulder range of motion (ROM) were recorded.ResultsTwenty patients, including eight with Neer two-part and 12 with three-part fractures, were followed-up, with a mean time of 12.3 months. All patients sustained fractures that healed without re-varus. During the last follow-up, the shoulder function of the patients had recovered well, with a mean VAS pain score of 1.4, a mean CSS of 83.1, a mean DASH score of 80.8, a mean ASES score of 84.0 and a satisfactory ROM. In one patient, the proximal locking screw came out and was removed via a second surgery.ConclusionsThe use of a locking intramedullary nail alone for initial varus proximal humeral two-/three-part fractures was feasible. This treatment has advantages, such as preventing re-varus and causing milder surgical trauma, than that seen with a locking plate.

Comparison of Locked Plating of Varus Displaced Proximal Humeral Fractures With and Without Fibula Allograft Augmentation.

To compare the clinical and radiographic outcomes between patients treated with fibula allograft-augmented locking compression fixation and patients treated with locking compression fixation alone for 2- and 3-part proximal humeral fractures with varus displacement. Retrospective review. Level 1 trauma center. One hundred two patients treated with locking plate fixation ± fibular allograft augmentation confirmed intraoperatively by visual inspection to have varus-angulated, 2- and 3-part proximal humerus fractures with at least 45 degrees of varus angulation at the neck/shaft and at least 1 cm of displacement. Proximal humerus locking plate (PHILOS; Synthes, Paoli, PA) with or without fibula allograft augmentation. Statistical analysis to determine the differences between fractures treated with locking compression fixation ± fibula allograft augmentation regarding complications, shoulder reported outcome measures, and patient ROMs (Visual Analog Score (VAS), Disabilities of the Arm, Shoulder and Hand, and Simple Shoulder Test scores). Medical comorbidities as potential risk factors for complication from surgery were also evaluated. Of 102 surgical cases, 27 were augmented with fibula allograft and 75 were not. Postoperatively, there were 16 noncatastrophic varus collapses of the fracture, 6 catastrophic varus collapses, and 5 deaths. Addition of fibula allograft did not significantly affect postoperative varus collapse, shoulder ROM, pain, or PROMs. Addition of fibula allograft to patients sustaining varus-angulated, 2- and 3-part proximal humeral fractures conferred no benefit to patient outcomes at our institution. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Strut Support with Tricortical Iliac Allografts in Unstable Proximal Humerus Fractures: Surgical Indication and New Definition of Poor Medial Column Support.

BackgroundThe execution of fibular allograft augmentation in unstable proximal humerus fractures (PHFs) was technically demanding. In this study, the authors evaluated the clinical and radiographic outcomes after tricortical iliac allograft (TIA) augmentation in PHFs.MethodsWe retrospectively assessed 38 PHF patients treated with locking-plate fixation and TIA augmentation. Insertion of a TIA was indicated when an unstable PHF showed a large cavitary defect and poor medial column support after open reduction, regardless of the presence of medial cortical comminution in preoperative images. Radiographic imaging parameters (humeral head height, HHH; humeral neck-shaft angle, HNSA; head mediolateral offset, HMLO; and status of the union), Constant score, and range of motion were evaluated. Patients were grouped according to whether the medial column support after open reduction was poor or not (groups A and B, respectively); clinical outcomes were compared for all parameters.ResultsAll fractures healed radiologically (average duration to complete union, 5.8 months). At final evaluation, the average Constant score was 73 points and the mean active forward flexion was 148°. Based on the Paavolainen assessment method, 33 patients had good results and 5 patients showed fair results. The mean loss of reduction was 1.32 mm in HHH and 5.02% in HMLO. None of the parameters evaluated showed a statistically significant difference between the two groups (poor and not poor medial column support).ConclusionsIn unstable PHFs, TIA augmentation can provide good clinical and radiological results when there are poor medial column support and a large cavitary defect after open reduction.

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

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. 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. In patients with 3-part fractures, no differences in clinical outcomes were found regardless of additional procedures. However, the FA 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). 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.

Locking plate plus endosteal fibular allograft augmentation for proximal humeral fractures with com-minuted medial column

Objective To evaluate the clinical and radiographic outcomes of locking plate plus endosteal fibular allograft augmentation for unstable proximal humeral fractures with comminuted medial col-umn. Methods We retrospectively analyzed the 48 patients who had been treated by locking plate plus endosteal fibular allograft augmentation and fully followed up for unstable proximal humeral fractures with comminuted medial column between June 2014 and March 2016. They were 12 men and 36 women, with an average age of 64.3 years (from 33 to 87 years). By the Neer classification, 7 cases were two-part fractures, 21 three-part fractures and 20 four-part fractures. Postoperative assessments included Constant-Murley scores, shoulder scores of Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH), Short Form Health Survey (SF12), humeral head height loss, change in humeral neck shaft angle, postoperative complications and revision rate. Results Their follow-ups averaged 16.7 months (from 12 to 30 months). Their final follow-ups showed a mean Constant score of 83.3 (from 67 to 98), a mean DASH shoulder score of 18.9 (from 6.6 to 49.9), and a mean SF12 of 82.8 (from 56 to 98). Postoperatively, the humeral head height loss averaged 1.2 mm (from 0.1 to 3.4 mm) and the neck-shaft angle 3.1° (from 0.1° to 9.1°). Compli-cations happened in 5 cases (10.4%): loss of reduction in one and screw penetration out of the articular surface in 4. Conclusion Locking plate along with endosteal fibular strut allograft augmentation is a promising technique for the treatment of proximal humeral fractures with comminuted medial column because fibular strut allograft may enhance mechanical stability of the humeral head, maintain fracture reduction, re-duce humeral head height loss and complications to ensure good clinical outcomes. Key words: Shoulder fractures; Fracture fixation, internal; Bone plates; Bone transplantation

The Outcomes of Proximal Humerus Fractures with Medial Metaphyseal Disruption Treated with Fibular Allograft Augmentation and Locking Plate

The Outcomes of Proximal Humerus Fractures with Medial Metaphyseal Disruption Treated with Fibular Allograft Augmentation and Locking Plate

Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation

Osteosynthesis of proximal humeral fractures is challenging in geriatric patients. The purpose of this investigation was to compare postoperative clinical outcomes between cohorts of geriatric (aged ≥65 years) and non-geriatric proximal humeral fracture patients treated via locked plating with endosteal fibular strut allograft augmentation. From March 2007 to January 2013, 71 adult patients with 2-, 3-, and 4-part proximal humeral fractures according to the Neer classification underwent osteosynthesis with locked plating and fibular allograft augmentation and had at least 12 months of clinical follow-up. All patients followed the same postoperative rehabilitation protocol. We compared the following between geriatric and non-geriatric patients: Disabilities of the Arm, Shoulder and Hand scores; University of California, Los Angeles shoulder ratings; Constant-Murley scores; and range of motion; as well as injury characteristics and radiographic outcomes. Geriatric patients comprised 48% of the study cohort (34 of 71 patients). The mean age of the geriatric and non-geriatric cohorts was 74 years and 53 years, respectively. Geriatric patients showed significantly reduced forward flexion (147° vs 159°, P = .04) when compared with non-geriatric patients. There were no significant differences in functional scores, radiographic outcomes, or complication rates between the 2 cohorts, although in 1 geriatric patient, osteonecrosis developed and screw penetration through the collapsed head was present 3 years after surgery. Osteosynthesis of proximal humeral fractures via locked plating with fibular strut allograft augmentation results in similar clinical outcomes between geriatric and non-geriatric patients. We believe that enhanced stability provided by this fixation construct allows early intensive postoperative therapy and results in excellent outcomes despite patient age.

Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus

The use of an intramedullary fibular allograft together with a locking plate fixation has been recently described in biomechanical studies to provide additional medial support and prevent varus malalignment for displaced proximal humeral fractures with promising results. The aim of this study was to evaluate the clinical and radiographic outcome of a locking plate with fibular allograft augmentation in unstable humeral fractures. We prospectively assessed the functional outcome and complications in 17 patients with proximal humeral fractures with disrupted medial column, treated with a locking plate and a fibular strut graft. The median patient age was 62 years. Postoperative assessments included radiographic imaging, range of motion, pain according to the visual analogue scale (VAS), Short Form (SF36) Health Survey, Constant-Murley and Disabilities of the Arm, Shoulder and Hand (DASH) shoulder scores as well as return to previous occupation and complications. No patients were lost to follow-up and no major complications were recorded. There was no collapse of the humeral head more than 2mm, osteonecrosis or screw penetration of the articular surface. All fractures healed clinically and radiographically. After an average follow-up of 13 months, the mean Constant score was 79 points. The mean active flexion was 149°; extension, 47°; internal rotation, 40°; external rotation, 65°; and abduction, 135°. The median VAS pain level was 1 point. The median DASH score was 33 points, and the median SF36 was 83 points. Locking plate with fibular graft augmentation is a safe and promising technique to support the humeral head and maintain reduction in the proximal humeral fracture with medial comminution.