Intramedullary Fibular Allograft Research Articles

Kickstand Technique for Treatment of Valgus-Impacted Proximal Humerus Fractures

Purpose: Describe a new technique using a minimally invasive surgical intervention for the treatment of valgus-impacted proximal humerus fractures. The Kickstand technique is a novel approach that offers reliable fixation and union without the need for additional hardware. Materials and Methods: A retrospective case series of 3 patients with valgus-impacted proximal humerus fractures was treated with this Kickstand technique using an intramedullary fibular allograft. Postoperative x-rays and outcomes are presented. Results: The Kickstand technique was used to address valgus-impacted fractures in 3 patients. Postoperative range of motion and shoulder outcome scores were reported at 2 years for patients A and B, and at 1 year for patient C (Active range of motion external rotation: 28 degrees; Active range of motion elevation: 140 degrees; Simple Shoulder Test-12: 11; American Shoulder and Elbow Standardized Shoulder Assessment: 78). Postoperative Grashey and lateral x-rays for each patient show union of the valgus-impacted humerus. Conclusions: The Kickstand technique using intramedullary fibular allograft is an alternative fixation technique for displaced valgus proximal humerus fracture. It has the advantage of avoiding additional metallic hardware and allowing early motion but requires the use of intramedullary fibular allograft which can interfere with future use of stemmed humeral prosthesis.

Use of an intramedullary fibular strut allograft and dual locking plate in periprosthetic fractures above total knee arthroplasty: new application of a well-known treatment method in trauma.

Augmenting fracture fixation with intramedullary fibular graft has seen several applications such as in comminuted proximal humerus fractures, and femoral neck and shaft nonunion. The purpose of this study was to report the first case series demonstrating the novel application of an intramedullary fibular allograft strut and dual locking plates on complicated periprosthetic fracture of distal femur. The patient demographics, weight-bearing status, and radiographic and clinical outcomes of six patients, who were treated for periprosthetic distal femur fractures using an intramedullary fibular allograft strut and dual locking plate, between January 2018 and April 2020 were analyzed. Postoperative range of knee motion showed median 10' (range 10-20) of flexion contracture and 90' (range 80-110) of further flexion. Postoperative joint function was assessed according to the Kolmert functional criteria, with "excellent to good" in angular deformity and "Good to fair" result in range of motion and pain. RUSH score was assessed, and median score was 24 (range 18-26). All patients were able to ambulate without assistance 6months after surgery. In summary, the application of fibular strut graft and dual locking plate might be an option in complicated distal femur fracture above total knee arthroplasty. Albeit with an available number, such application showed promise as an intramedullary and cortical support for both reduction and maintenance of correction alignment, length, and prevention of further angular deformity. Surgical technique and Cases-series.

The potential of locking plate with intramedullary fibular allograft to manage proximal humeral fracture with an unstable medial column.

To evaluate the potential of locking compression plate with intramedullary fibular allograft in managing proximal humeral fractures with an unstable medial column. Between March 2007 and March 2015, we retrospectively analyzed 63 patients who underwent locking plate fixation for proximal humeral fracture with an unstable medial column. All patients were assigned into group 1 (patients treated with locking plate) and group 2 (patients treated with locking plate with intramedullary fibular allograft). Groups 1 and 2 were composed of 29 and 34 patients, respectively. We analyzed bone union, the neck-shaft angle, the Constant score, the range of motion, and complications. The mean average bone union time of the patients was 13.9weeks in group 1 and 11.3weeks in group 2. The average Constant score was 67.4 in group 1 and 73.6 in group 2 (p < 0.05). The mean preoperative NSA, postoperative NSA, and NSA at the last follow-up were 104.4°, 125.8°, and 115.8°, respectively, in group 1, and 109.0°, 130.3°, and 127.1°, respectively, in group 2. The mean forward flexion, abduction, external rotation, and internal rotation were 109.0°, 48.2°, 34.0°, and L5, respectively, in group 1, and 127.5°, 118.2°, 38.7°, and L1, respectively, in group 2. In group 1, avascular necrosis occurred in one patient and screw cutout in two patients. In group 2, screw cutout occurred in one patient. In patients aged over 65years with proximal humeral fractures, an unstable medial column was associated with poor clinical results owing to varus collapse. To prevent this, an intramedullary fibular allograft was used, and radiologic and clinical results were better with this approach than with a locking plate alone. Therefore, locking plate fixation using a fibular allograft is one of the possible treatments for patients with an unstable medial column.

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.].

Reverse Shoulder Arthroplasty for Failed Proximal Humerus Osteosynthesis With Intramedullary Allograft: A Case Series

Introduction The presence of retained intramedullary fibular allograft presents many challenges during reverse shoulder arthroplasty (RSA), which have been discussed in limited fashion. This case series presents a single-surgeon experience with 6 patients treated with RSA following failed osteosynthesis of proximal humerus fractures using intramedullary allografts. Methods A retrospective review was conducted of RSA patients with a minimum of 2-year follow-up (exception of 1 deceased patient) for failed plate fixation of proximal humerus fractures. Two cohorts were created based on the presence of an intramedullary allograft during the procedure. Patient-reported outcome measures, active range of motion, time to revision, surgical time, complications, and case descriptions were obtained from chart review and radiographic analysis. Results When treating patients with a retained allograft, the surgeon used a guide pin from a cannulated screw set to advance through the graft, and a cannulated drill was used to ream and bypass the allograft, contributing to a 22% increase in surgical time (151 vs 124 min). Intraoperative complications were observed only in the allograft cohort (50%; 3 of 6), including cortical perforation with cement extrusion, humeral loosening, and proximal humerus bone loss. Patients treated with a retained allograft experienced pain relief ( P = .001) but did not gain significant functional improvements. Conclusion RSA for failed proximal humerus fixation with healed intramedullary allograft is associated with increased operative time and intraoperative complications, and patients can mostly expect pain relief. Techniques for humeral canal preparation and stem placement to bypass the allograft are helpful in managing these revisions.

Hemi- vs. reverse shoulder arthroplasty for acute proximal humeral fractures

To date, there is no clear consensus on the superiority of shoulder hemiarthroplasty (HSA) or reverse shoulder arthroplasty (RSA) for the treatment of acute proximal humeral fractures (PHF). The aim of this study was to review the relevant literature for level I and II studies reporting clinical outcomes and revision rates for HSA or RSA in the treatment of acute PHF. Two electronic databases (PubMed, and Embase) were systematically searched for level I and II studies published after 1998 reporting clinical and/or radiographic outcomes of primary HSA or primary RSA as treatments for acute PHF. Of the 628 studies that were identified, nine were selected (four level I and five level II), with some heterogeneity in describing outcomes, complications, and revisions. The three studies that compared HSA versus RSA in patients with a mean age of >70 years found that RSA grants better clinical scores, less pain, higher forward elevation, and greater patient satisfaction. The remaining six studies compared outcomes of acute PHF treated by conventional HSA versus HSA + biceps tenodesis, trabecular metal HSA, intramedullary fibular allograft with locking compression plates, open reduction with internal fixation, or nonoperative treatment. Reverse shoulder arthroplasty is a reliable treatment for acute PHF in elderly patients, which grants better outcomes and is associated with fewer complications than HSA at short-term follow-up. Future research is needed to establish the best surgical treatment for acute PHF in young patients. Level II, systematic review of level I and II studies.

The Augment of the Stability in Locking Compression Plate with Intramedullary Fibular Allograft for Proximal Humerus Fractures in Elderly People.

Objective The objective of this study was to compare the clinical outcomes and complications between the locking compression plate (LCP) and LCP with fibular allograft in the treatment of patients with displaced proximal humerus fracture (PHF) in elderly people. Material and Methods Between January 2010 and December 2013, a total of 97 elderly patients with displaced PHF were treated by LCP or LCP with fibular allograft, and finally 89 patients were included in our study. All the patients were divided into Group I (patients treated by LCP) and Group II (patients treated by LCP with fibular allograft). Function results were assessed by the disability of the arm, shoulder, and hand (DASH) score and Constant-Murley score (CMS), and complications were also recorded in each group. Results The average follow-up was 35.2 months (range, 24-48 months) in Group I and 33.5 months (range, 24-48 months) in Group II. DASH in patients of Group I was significantly higher than that in patients in Group II and patients of Group I had CMS scores significantly lower than patients in Group II (P<0.05). The rates of varus malunion, screw perforation, and loss of reduction>5mm were significantly higher in Group I than in Group II (P<0.05). Conclusions The present results showed that that patients treated by LCP with fibular allograft had a better functional outcome and a lower complication rate compared to patients treated by LCP alone. Suitable void filler in the proximal humerus for supporting the head fragment, medial cortical bone, and greater tuberosity might play a key role in reducing the incidence of the complications in elderly patients, especially with osteoporosis.

Allogreffe fibulaire impactée et plaque verrouillée versus hémiarthrosplastie d’épaule dans les fractures 4 fragments proximales de l’humérus ostéoporotique : une étude prospective consécutive

ObjectivesTo compare the outcomes of intramedullary fibular allograft (IFA) with locking compression plates (LCPs) versus shoulder hemi-arthroplasty (HA) in osteoporotic four-part proximal humeral fracture (PHF). MethodsBetween January 2010 and December 2012, totally 60 cases with osteoporotic four-part PHF were enrolled in this study and were randomly separated into IFA and LCPs group and HA group (n=30). Additionally, surgery indexes for patients in the two groups, such as constant-Murley score (CMS), the disability of arm, shoulder and hand (DASH) score, individual subject evaluation of the outcomes, plain X-ray, and computer tomography (CT) scanning were evaluated and compared. ResultsCMS, DASH score, activities of daily living (ADL), and range of motion (ROM) were statistically higher in the IFA and LCPs group than those in the HA group at the last follow-up, whereas the pain were obviously lower than that in the HA group. Besides, patients in the IFA and LCPs group had higher abduction, external rotation with elbow, strength, and satisfactory rating compared with HA group at the last follow-up. However, one case developed avascular necrosis (AVN), one case encountered screw perforation, and one case experienced varus displacement in the IFA and LCPs group, while there were 2, 4, and 2 cases suffered from superficial infection, shoulder stiffness, tuberosity migration in the HA group, respectively. ConclusionIFA with LCP have an advantage in functional outcomes than shoulder HA.

Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemi-arthroplasty for repair of osteoporotic four-part proximal humerus fracture: Consecutive, prospective, controlled, and comparative study

ObjectivesTo compare the outcomes of intramedullary fibular allograft (IFA) with locking compression plates (LCPs) versus shoulder hemi-arthroplasty (HA) in osteoporotic four-part proximal humeral fracture (PHF). MethodsBetween January 2010 and December 2012, totally 60 cases with osteoporotic four-part PHF were enrolled in this study and were randomly separated into IFA and LCPs group and HA group (n=30). Additionally, surgery indexes for patients in the two groups, such as Constant-Murley score (CMS), the Disability of Arm, Shoulder and Hand (DASH) score, individual subject evaluation of the outcomes, plain X-ray, and computer tomography (CT) scanning were evaluated and compared. ResultsCMS, DASH score, activities of daily living (ADL), and range of motion (ROM) were statistically higher in the IFA and LCPs group than those in the HA group at the last follow-up, whereas the pain were obviously lower than that in the HA group. Besides, patients in the IFA and LCPs group had higher abduction, external rotation with elbow, strength, and satisfactory rating compared with HA group at the last follow-up. However, one case developed avascular necrosis (AVN), one case encountered screw perforation, and one case experienced varus displacement in the IFA and LCPs group, while there were 2, 4, and 2 cases suffered from superficial infection, shoulder stiffness, tuberosity migration in the HA group, respectively. ConclusionIFA with LCP have an advantage in functional outcomes than shoulder HA. Level of evidenceLevel II. Prospective cohort study.

Locking plate fixation combined with iliac crest bone autologous graft for proximal humerus comminuted fracture.

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. 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. 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. Locking plate fixation combined with an iliac crest bone graft is an effective technique for treating proximal humerus comminuted fractures.

Treatment of Atrophic Diaphyseal Humeral Nonunions With Compressive Locked Plating and Augmented With an Intramedullary Strut Allograft

The aim of this study was to evaluate the effectiveness of thorough debridement and locked compression plating augmented with an intramedullary fibular allograft for the treatment of atrophic diaphyseal humeral nonunions. The study involved a level 4 retrospective case series. This study was conducted at a level 1 university trauma center. Twenty patients with painful atrophic nonunions of the humeral diaphysis were examined. This involved a thorough debridement and locked compression plating augmented with an intramedullary fibular allograft. These were union rate, shoulder range of motion, visual analog scale (VAS) pain, VAS function, patient satisfaction, and American Shoulder and Elbow Surgeons score at latest follow-up. Clinical and radiographic examinations were performed preoperatively and postoperatively. VAS pain and function scores were collected preoperatively and postoperatively. Patient satisfaction and ASES scores were recorded at the time of the most recent follow-up. : Bony union was achieved in 19 of 20 patients (95%). The patients demonstrated an average improvement in forward elevation from 65 to 144° (P = 0.001), abduction from 48 to 133° (P < 0.001), external rotation from 34 to 70° (P = 0.05), and internal rotation from S1 to T12 (P = 0.025). VAS pain scores improved from 6.05 to 1.88 (P = 0.032). VAS function scores improved from 2.06 to 7.75 (P = 0.003). The average postoperative ASES score was 76, and the average patient satisfaction was rated 9.3/10. Atrophic nonunions of the humerus can be successfully treated with debridement of the nonunion, coupled with the use of a fibular allograft and locked compression plating. This technique leads to predictable healing without the morbidity associated with autograft. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft

Background Loss of locking plate fixation has been reported in proximal humeral fractures, particularly in older patients with poor bone density. In such fractures, the medial support between the humeral head and shaft is occasionally missing, resulting in varus collapse of the construct. A biomechanical study was performed to understand the behaviour of the interface of these fractures fixed with a locking plate fixation with and without augmentation. The augmentation consisted of an intramedullary fibular allograft (bone peg) that has been reported for use in these fractures. Methods Six embalmed pairs of specimens were utilized; each pair of specimens had one humerus repaired with the locking plate fixation, and the other humerus repaired with the plate fixation and bone peg. The constructs were tested in bending to determine the relative movement between the humeral head and the shaft under bending loads, and the failure loads of both constructs. Digital Imaging Correlation was used to determine the relative movement. Findings The bone peg increased the failure load of the constructs by 1.72 (SD 0.54) times ( P = 0.02). The relative movement was measured by comparing the initial stiffness of both constructs. Initial stiffness of the construct was increased 3.84 (SD 1.92) times ( P = 0.005) with the use of the bone peg. Interpretation The intramedullary bone peg significantly decreases the relative movement at the interface. Further studies are needed to accurately determine the effect this reduction has on the healing process, and overall clinical result.

Treatment of Humeral Nonunions with Allograft, Demineralized Bone Matrix, and Plate Fixation

Objective: Due to the risks inherent in autologous iliac crest bone graft harvest, the results of patients with humeral nonunions who were treated with allograft, demineralized bone matrix, and plate fixation were evaluated. Design: Retrospective review of patients who underwent operative treatment of humeral nonunions with allograft, demineralized bone matrix, and plate fixation. Setting: University medical center. Patients: Ten patients with nonunions of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 2 years follow-up were included. The mean duration of the nonunion preoperatively was 24 months (range, 4-120 months). The patients had undergone an average of one (range, 0-3) previous surgery on the humerus. Intervention: Open reduction and internal fixation with plate and screw fixation and bone graft. All ten patients had bone grafting with cancellous allograft and demineralized bone matrix, while four of the ten also had intramedullary fibular allograft supplementing the fixation in cases of osteopenia or bone loss. Main Outcome Measures: Clinical and radiographic evidence of bone union. Medical records, operative reports, physical examination, and preoperative, postoperative, and follow-up radiographs were reviewed. Outcomes were assessed with the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) to evaluate subjective outcome. Results: At a mean follow-up of 33 months (range, 25-42 months; minimum, 2 years) 9 of the 10 nonunions (90 %) had healed. One patient required a second operation to gain union. The nonunion that failed to heal, in a patient with severe coronary artery disease and congestive heart failure, initially healed at 3 months but at 40 months postoperatively had refractured through the old nonunion site with loss of internal fixation after a fall at home. Patient outcomes evaluated with the DASH questionnaire demonstrated 3 excellent, 4 good, 2 fair, and 1 poor result at follow-up. All patients with healed fractures at follow-up had functional shoulder and elbow range of motion. Conclusions: These results show that allograft and demineralized bone matrix can be a useful adjunct to plate fixation in the treatment of humeral nonunions, even in patients who have had previous surgery.