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108 © 2018 Indian Journal of Orthopaedics | Published by Wolters Kluwer - Medknow
Address for correspondence:
Dr. Venkat Kavuri,
Department of Orthopaedic
Surgery, Drexel University
College of Medicine,
Hahnemann University Hospital,
245 N. 15th St. M.S. 420,
Philadelphia, PA 19103, USA.
E-mail: vckavuri@gmail.com
Access this article online
Website: www.ijoonline.com
DOI:
10.4103/ortho.IJOrtho_243_17
Quick Response Code:
Abstract
Proximal humerus fractures constitute a signicant percentage of fragility fractures. The growing
use of locking plate has helped treat this problem, but at the same time has brought about
complications. Past systematic reviews have documented these complications, however a large
number of recent studies have been published since, reporting their own complication rates with
different techniques. This study reviews the current complications associated with locking plate
of proximal humerus fractures as well as methods to reduce them. A systematic review, following
the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using
PubMed, Scopus, and Cochrane databases, to evaluate locking plate xation (and complications) of
traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of
12-monthpostoperativefollowup,articleswithinthelast5years,andstudieswith>10participants.
Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible
studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were
included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery
andCentre forEvidence-BasedMedicineguidelines.The initialquery identied51,206articles from
multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting
of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal
humerusfracturestreated with locking plates.Intraarticularscrewpenetration was the mostreported
complication(9.5%),followedby varuscollapse (6.8%),subacromial impingement(5.0%), avascular
necrosis(4.6%),adhesivecapsulitis(4.0%),nonunion(1.5%),anddeepinfection(1.4%).Reoperation
occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-
related complications, which in turn were the main reasons for reoperation. The authors of these
studies discussed different techniques that could be used to address these issues. Expanding use of
lockingplate intheproximal humerusfractures leadstoimprovements andadvancementsinsurgical
technique.Further researchisnecessary tooutlineindications todecreasecomplications, further.
Keywords: Fracture, proximal humerus, locking plate,complications
MeSH terms: Bone plates, humeral fractures, proximal, surgical complications
Complications Associated with Locking Plate of Proximal Humerus
Fractures
Venkat Kavuri,
Blake Bowden,
Neil Kumar,
Doug Cerynik
Department of Orthopaedic
Surgery, Drexel University
College of Medicine,
Hahnemann University Hospital,
Philadelphia, PA, USA
How to cite this article: Kavuri V, Bowden B,
Kumar N, Cerynik D. Complications associated with
locking plate of proximal humerus fractures. Indian J
Orthop 2018;52:108-16.
Introduction
Proximal humerus fractures represent
a steadily growing problem within the
health-care system. Proximal humerus
fractures are the third-most common type
of fragility fracture, accounting for nearly
6% of all adult fractures.1,2 In addition,
as the world’s population has aged, the
incidenceof thisfracturetype hasincreased
as well.3 Surgical intervention for this
fracture type is around 20%, due to the
increase in complications as patients age.3,4
Surgical xation with locking plates is
the most common type of intervention
for displaced proximal humerus fractures,
though other options exist, such as closed
reduction with percutaneous pinning,
hemiarthroplasty,proximal humeral nailing,
andreversetotal shoulderarthroplasty.4,5
Locking plate represents a relatively new
technology that theoretically supports
xation in the setting of osteoporotic
bone.6 Its biomechanical properties made
it promising in the setting of proximal
humerus fractures, where purchase in the
humeral head is difcult to obtain, due
to large variations in bone density and
strength.7 Understandably, complications
were highly variable as locking plates
rst began to be used in the proximal
humerus fractures. The rst systematic
review in this setting noted the importance
of medial calcar support and the need for
more attention to technical aspects of the
procedure.8Sproul etal. performed another
review with a focus on length of followup,
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Review Article
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018 109
tomore accuratelycapturethetimeframenecessaryforthe
development of avascular necrosis (AVN) of the humeral
head.Thestudyconrmed factorsforscrewcutoutand had
similarrates of complications.9
Since the publication of these two reviews, there has been
anincreaseintheliterature,regardinglockingplatexation
for proximal humerus fractures. In addition, studies have
attempted to curtail the complication rates mentioned
earlier with augmentation strategies such as bular strut
allograft, autograft, cancellous chips, suture xation of the
rotatorcuff,anddenedtechnicalsteps,regardingplateand
screw placement. Recent years have shown an increase in
the indications for the use of locking plates, as well as
reverse total shoulder arthroplasty versus hemiarthroplasty
in the setting of proximal humerus fractures.10,11 Given
the relative infancy of locking plate xation at the time of
prior systematic reviews, and the small number of studies
included within each review, a more recent systematic
review of the literature is warranted. This study examines
thecurrentliteraturetoevaluatecomplicationsexperienced
withlockingplateinlightofchangestooperativetechnique
asfamiliaritywith thisimplanthas increased.
Materials and Methods
Following preregistration with PROSPERO
(CRD42015019038), a comprehensive search of the
literature was performed in November 2013 and repeated
in February 2015, to capture recent publications, utilizing
the PubMed, Cochrane, and Scopus databases.12 Database
queries were performed using modiers, limiting results to
publications in the English language of the past 10 years,
in studies involving human subjects. Search terms were
intentionallybroadtoidentifyallrelevantarticles[Table1].
Thestudy designwasconductedstrictlyin accordancewith
the PRISMA guidelines.12 The results were subsequently
ltered for duplicates, and titles and abstracts were
manually screened for relevance and potential adherence
to our inclusion criteria. To be included, eligible studies
must have been conducted in the past 5 years (modier in
initial query was 10 years to ensure broadness of search),
involving 10 or more subjects, adults aged 18 years or
older, and a minimum average followup of 12 months.
International studies with the English translation were
included.Studiesinvolving pathologicfractures,nonhuman
subjects (invitro studies), and cadavers were excluded.
Publications with overlapping or duplicate patient
populationswere excluded.
Next, articles were assigned a quality score using a
previously published quality scoring system, which was
also used by Sproul etal.9,13 The scoring system took into
accountthequalityofthestudydesign,aswellasthequality
of its information. Two reviewers scored the articles and
onlystudies with a minimum score of7/10 were included.
Disagreements were resolved by consensus. Finally, the
studiesweregradedinaccordancewiththeJournalofBone
andJoint SurgeryandCentre forEvidence-BasedMedicine
guidelines, to universally assess the level of evidence of
each study. Statistics were performed by authors with
training in biostatistics. Complication rates were analyzed
in a simple manner, rst divided by the total number of
fractures treated and followed by stratication by level of
evidence. There were no comparative analyses performed
duetothe heterogeneityofeach study.
Results
The initial query conducted through the PubMed, Scopus,
and Cochrane databases identied 51,206 citations. After
removing duplicates and articles with irrelevant titles and
abstracts, a total of 191 full-text articles were assessed
for eligibility. From these 191 articles, 57 articles were
includedto be a part of this systematic review.Theresults
of screening and application of inclusion/exclusion criteria
areoutlined in Figure1.14-70
Therewereseven Level 1, threeLevel2,10Level 3, and
37Level 4studies.Level 1and2 studiesincludedcontrol
groups in regard to surgical approaches, nonoperative
treatment, various treatment modalities, or deferring
operativetechniques.SomeLevel3studieshadabasisfor
comparisonwhenevaluatingdifferent surgicalapproaches
or operative techniques. Finally, Level 4 studies were
caseserieswithout a basis forcomparison.Someof these
series investigated techniques such as strut allografts,
suture xation, bone grafting, and minimally invasive
surgery.
There were a total of 3422 proximal humerus fractures that
were treated with locking plate. Certain studies failed to
mentionorreportthepresenceorabsenceofcomplicationsthat
werespecically beinginvestigated.If thisoccurred,thestudy
was not included in the complication’s analysis. The most
common complication was intraarticular screw penetration
(9.5%), followed by varus collapse (6.8%), subacromial
impingement(5.0%),AVN(4.6%),adhesivecapsulitis (4.0%),
nonunion (1.5%), and deep infection (1.4%). Reoperation
Table 1: Search terms used in the PubMed, Cochrane,
and Scopus databases
Proximalhumerus AND Screw
Plate
Lockingplate
LCP
PHILOS
S3
Fracturexation
Fracturehealing
Openreductioninternalxation
Osteosynthesis
Humerusfracture
Shoulder
LCP=Lockingcompressionplate
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
110 Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018
occurred at a rate of 13.8%. Tables 2-9 display these rates of
complicationsbroken down bylevelsof evidence.
Discussion
Intraarticular screw penetration (9.5%)
Intraarticular screw penetration through the humeral head
has been noted as a problematic complication and may lead
to additional surgery to revise or remove the screw(s). Two
different screw penetrations have been discussed: primary
and secondary. Primary screw penetration refers to the
intraoperative placement of screws into the glenohumeral
joint. Secondary screw penetration refers to the screws that
have violated the articular surface as a result of collapse of
the humeral head due to varus collapse, AVN, or failure of
xation.Reports fromtheearlierliteratureshowtheprevalence
of this complication to range from 0% to 23%.71 Sproul etal.
demonstratedthis complication tobeat a rateof7.5%.9
Level 1
Fjalestad etal. reported that the majority of these
complications occurred in patients with Orthopaedic
TraumaAssociation(OTA)TypeCfractures,withevidence
of AVN.27 Another study noted that attempts to obtain
maximalpurchase intothehumeral headledtohigherrates
of primary screw penetrations. The authors adjusted their
surgical technique by placing screws 2 mm–3 mm away
fromthesubchondralbone,aswasdoneinanotherlevel1
study.48,70 In comparing different plates, Voigt etal. found
that polyaxial locking screws with blunted ends could be
advantageousif screw penetrationwereto occur.65
Level 2
Buecking etal. observed that complications pertaining
to the humeral head were higher in their deltoid-splitting
Table 4: Rate of subacromial impingement
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 1 27 3.7
2 5 270 1.8
312 217 5.5
488 1616 5.5
Total 106 2130 5.0
Table 6: Rate of adhesive capsulitis
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
17 75 9.3
2 Notreported Notreported -
36 150 4.0
436 1015 3.5
Total 49 1240 4.0
Table 2: Rate of intraarticular screw penetration
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 40 192 20.8
2 71 360 19.7
357 639 8.9
4129 1951 6.6
Total 297 3142 9.5
Table 3: Rate of varus collapse
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
111 116 9.5
2423 17.4
3 19 316 6.0
450 788 6.3
Total 84 1243 6.8
Table 7: Rate of nonunion
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 3 272 1.1
2 Notreported Notreported -
36 389 1.5
424 1544 1.6
Total 33 2205 1.5
Table 5: Rate of avascular necrosis
Level Percentage of
occurrences
Percentage of
fractures
Rate
118 283 6.4
24113 3.5
321 489 4.3
488 1956 4.5
Total 131 2841 4.6
51,206 records
11,450 records
PubMed
8,776 records
Cochrane
1,012 records
Scopus
41,418 records
39,756 duplicates
191 full-text articles
11,259 titles/abstracts
excluded
57 articles included
134 articles excluded
Figure 1: Flowchart showing selection of studies
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018 111
approach group, while complications pertaining to the
humeral shaft were higher in their deltopectoral approach
group.19Konrad etal.reportedscrew penetration,notvarus
collapse or loosening, as the most common complication
with locking plate in their large multicenter study of
270patients.34
Level 3
Ina studycomparinglockingplate xationwithcalcium
phosphate cement augmentation versus cancellous bone
chips versus no augmentation, Egol etal. demonstrated
a signicant decrease in intraarticular screw penetration
with calcium phosphate cement augmentation. In
addition, there was no association between the number
of screws in the humeral head and screw penetration.
However, age was associated with screw penetration
as elderly patients sustained this complication more
frequently.26
Level 4
Little etal. described ve incidences of asymptomatic
screw penetration in their series evaluating 72 cases, for
which endosteal augmentation was used. The authors
believed that this intramedullary graft decreased the
working length of the locking screws.38 Ricchetti etal.
reported no cases of screw penetration in their series
of 54 fractures followed for 13 months. The authors
described using screws 5 mm–10 mm away from the
subchondralboneto decrease theriskofscrew perforation
both primarily and secondarily, should collapse occur.
This technique has also been reported in a review article
by Ricchetti et al.52,71 Spross etal. noted that, by placing
screws 4 mm–5 mm away from the subchondral bone,
complications regarding intraarticular screw penetration
decreased signicantly. They also advocated the use of
uoroscopyinthreeplanesinanattempttoavoidmissing
primaryscrew penetrations.62
Varus collapse (6.8%)
Varus collapse represents one of the more important
complications in the setting of locking plate in proximal
humerus fractures. Varus collapse is responsible for
secondarysubacromial impingement and screw penetration
into the articular surface of the glenohumeral joint. Sproul
etal. reported this as the most common complication in
theirreview,at arateof16.3%.9Theauthorsrecommended
thatspecial attention should be paid to the medial column,
which has led some surgeons to place inferomedial
support screws, cement, or graft in hopes of lowering this
complicationrate.
Level 1
In comparing polyaxial versus monoaxial locking screws,
Voigt etal.notedan increaseintherate ofvarusdeformity
in the group treated with monoaxial screws. The authors
felt that polyaxial screws gave more options for screw
placement inferomedially.65 Zhang etal. postulated that
inferomedially placed support screws would resist varus
stresstothehumeral head,thereforemaintainingneckshaft
anglein three- andfour-partfractures.69
Level 2
Evaluating a new carbon ber–reinforced-
polyetheretherketone (CFR-PEEK) locking plate,
Schliemann etal. showed a lower rate of varus deformity
in comparison to the control titanium locking plate. They
believed that this was due to CFR-PEEK being less rigid
andhavinga similarelasticmodulus to bone.58
Level 3
Linetal.reportedlowratesof varus collapse in both their
minimally invasive and deltopectoral approach groups.
However, they attributed a slightly higher rate within the
minimally invasive group due to a false sense of security
with progression through weight-bearing exercises because
offasterwound healingandsmaller scars.37
Level 4
Ricchetti etal. discussed additional contouring of the
locking plate as a method to reduce the incidence of
varus malunion as it aids in obtaining an anatomic
neck–shaft angle. In addition, they placed bone graft for
complicated three- and four-part fractures.52 Kim etal.
performed a study using autologous iliac bone impaction
graft with locking plate of four-part fractures and
reported 0 incidences of varus collapse in 21 cases over
a 27.5-month followup period. The authors believed that
their meticulous attention to restoring the medial calcar,
obtaining sufcient screw purchase in the inferomedial
aspect of the humeral head, and suturing the rotator cuff
to the plate led to such positive results.32 Badman etal.
reported on 81 proximal humerus fractures, a majority of
which were three-part fractures. The authors focused on
Table 8: Rate of deep infection
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 1 124 0.8
2 5 360 1.4
36439 1.4
426 1790 1.5
Total 38 2713 1.4
Table 9: Rate of reoperation
Level Percentage of
occurrences
Percentage
of fractures
Rate (%)
1 34 227 15.0
2 25 113 22.1
362 529 11.7
4228 1658 13.8
Total 349 2527 13.8
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
112 Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018
supplemental suture xation of the rotator cuff in the ve
casesof varuscollapseandalsoused structuralallograftin
thesetting of severeosteopenia.16
Subacromial impingement (5.0%)
Subacromial impingement can be the result of poor
intraoperative plate positioning or the sequelae of humeral
head collapse. Impingement is frequently symptomatic
and may require plate removal. Sproul etal. reported this
complicationat a rateof4.8%.9 Increasedattentiontoplate
placement and preventing varus collapse are the methods
surgeonsare usingtodecreasethis complication.
Level 1
Only one study mentioned a case of subacromial
impingement. Olerud etal. reported one patient in their
treatment group of 27 cases with three-part fractures,
who subsequently required plate removal. The authors
recommended averting humeral head collapse to prevent
thiscomplication.48
Level 2
Konrad etal. attributed their cases of impingement to
placing the plate too superiorly, leading to ve cases in
theirstudy population of270.34
Level 3
Lin etal. attributed their cases of impingement to varus
collapse, while Jung etal. attributed their one case to
intraoperativeerror.31,37Jungetal. describedtheiroperative
positioning of the plate following reduction as caudal to
thesuperior end of the greater tuberosity and lateral tothe
bicipital groove.31 Bachelier etal. instead specied plate
position 1 cm caudal to the superior aspect of the greater
tuberosity.15
Level 4
Sahureportednocase of impingement, taking the shoulder
througharangeofmotion arc before closure of the wound
to detect any symptoms of impingement.55 Osterhoff etal.
describedthemajorityof their 10 cases of impingement to
be strongly associated with medial calcar comminution.49
Ricchetti etal. positioned the locking plate 5 mm–10 mm
lateraltothe bicipital grooveand15mm–20 mm caudalto
thetipof thegreatertuberosity.Twopatients in theirseries
of 54 cases had postoperative subacromial impingement
symptoms.52 Finally, Aggarwal etal. described
provisionallyxing the plate with K-wires and placing the
shoulder through a range of motion arc under uoroscopy.
This technique resulted in ve cases of impingement in
theirseries of 47.14
Avascular necrosis (4.4%)
AVN has been a historic concern with proximal humerus
fractures. Sproul etal. reported this rate to affect 10.8%
of patients.9 This has even led to studies attempting to
discover predictors of necrosis, following a proximal
humerus fracture. Hertel etal. determined that the most
relevant factors included integrity of the medial hinge,
length of the dorsomedial metaphyseal extension, and
different fracture types.72 Furthermore, growing indications
for reverse total shoulder arthroplasty and recent favorable
studies in comparison to hemiarthroplasty may have
articially decreased the rate of AVN currently being
reported.73 In addition, AVN may present later in followup
and inadequate lengths of followup would, in turn, under
report this complication. Recent studies have attempted to
use deltoid-splitting or minimally invasive approaches with
thebeliefthat less soft tissue disruption in proximity to the
humeral head would preserve its blood supply. Finally,
thereis growingbeliefthatasymptomatic casesofAVN can
potentiallyover-report thisseriouscomplication.
Level 1
Comparing the minimally invasive approach to the
deltopectoral approach, Liu etal. reported one case of
AVNinthelattergroupandzero inthe former.Theauthors
believed that the minimally invasive approach decreased
softtissuestrippingand preserved the bloodsupplyaround
the proximal humerus.39 Zhang etal. reported only one
case ofAVNin their study that focused on medial support
screws using a deltopectoral approach. In their opinion,
preventingmedialcollapsealso aided in preventingAVN.69
Interestingly,the ndings fromFjalestadetal.showedthat
nonoperatively treated patients had a higher rate of AVN
thanthoseintheoperativegroup.Allpatientshaddisplaced
three-andfour-partfractures.27
Level 2
Bueckingetal.reported no case ofAVNand nodifference
between deltoid-splitting and deltopectoral approaches.
Followup,however,wasonlyfor1year.19Schliemannetal.
reportedalower incidence ofAVN in patients treated with
theirCFR-PEEKimplantcomparedtoconventionallocking
plate.Their followupwasfora minimumof2years.58
Level 3
Martetschlager etal. reported higher rates of AVN in
patients treated with a deltopectoral approach compared
to a minimally invasive deltoid-splitting approach. With a
mean followup of nearly 4 years, AVN was diagnosed in
six of 33 patients in the deltopectoral approach group and
oneof37patients in the deltoid-splittingapproachgroup.41
Wu etal. reported similar ndings over a mean followup
of2.5yearsincomparinga minimallyinvasive approachto
adeltopectoral approach.67
Level 4
Using a minimally invasive plating technique and a mean
followup of nearly 3 years, Chen etal. reported only one
case of AVN in their series of 64 cases.21 Little etal.
reported low rates of AVN as well by using a deltoid
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018 113
splitting approach and a medial strut allograft.38 On the
otherhand,Sprossetal.reported 20 cases ofAVN in their
large case series of 294 followed for 1 year. The patients
were treated using a deltopectoral approach. The authors
determined,however,thatfracture type inuenced whether
AVN occurred or not, with fracture dislocations having the
highestrate.62
Reoperations (13.8%)
Reoperations are a very important measure of how
successful the index operation was and also highlight the
most signicant complications. Reoperations also highlight
possible improvements in surgical decision-making or
technique to avoid certain complications. Even in regard
toAVN,more meticulous soft tissuemanagement,attempts
at minimally invasive techniques, and consideration of
arthroplasty as primary surgery have led to a decrease
in reoperation. It is also important to make a distinction
between“planned”versus“unplanned”operationsasmany
patients do request to have hardware removed. Hardware
removal has been associated with a very low complication
rate and high patient satisfaction as indicated in a recent
case series.74 This should be differentiated from the need
toundergoanarthroplasty procedure due to failed primary
openreductionand internalxation(ORIF).
Level 1
Cai etal. reoperated on three of 12 patients following
lockingplate.Thepatientsoriginallyhadfour-partfractures
and reoperations were during the 2nd year of followup.
Plates were removed for xation failure and revision
internal xation for nonunion.20 Zhu etal. performed ve
screw revisions due to primary screw penetration.70 Voigt
etal. attributed the majority of reoperations in their study
duetosecondary displacementofthe greater tuberosity.65
Level 2
Buecking etal. reported a large number of reoperations:
three screw revisions, 18 plate removals, four revision
ORIF, and seven arthroplasties in their study population of
90.19 Seventeen of the plate removals were at the request
of the patient and the rest were due to screw perforation,
implant loosening, or infection. Schliemann etal.
performed seven plate removals with arthrolysis in two of
thosecases.58
Level 3
Kralinger etal. reported mechanical failure as a strong
predictorofreoperationintheirstudyconsistingofmajority
three- and four-part fractures. Two revision arthroplasties,
six capsular releases, six revisions of internal xation,
14 plate removals, and one hematoma evacuation were
performed.35 Sanders etal. discussed screw revisions and
plateremovals secondarytointraarticularscrewpenetration
and impingement, respectively,as a major reason for their
50%reoperation rate.56
Level 4
Ockert etal. noted an unplanned reoperation rate of 14%
andaplannedreoperationrate(duetoimpingement,patient
request, or range of motion decit) of 40% in its series of
43 patients followed for 10 years.46 Kim etal. reported
2 implant removals for cultural reasons in their case
seriesof 21 four-part fractures followed for 27.5months.32
Finally,Schliemann etal. reported impingement and screw
penetration as the primary reason their revision rate was
closeto 30%.57
The data presented in this systematic review not only
support data from past reviews but also present potential
solutions proposed by investigators, in the hopes of
decreasing the complication rate associated with locking
plate of proximal humerus fractures. Recent reviews have
emphasizedtheimportanceofAVNandfracturedislocation
patterns negatively impacting outcome. Complex,
intraarticularfracturepatternshavehighcomplicationrates
when treated with locking plate. Brorson etal. also noted
that the methodological quality of studies is lacking.75
Tepass etal. noted that three- and four-part fractures
actually had better outcomes when treated with head
preservingsurgery comparedtoa hemiarthroplastyandthat
there were an increase in the number of complications as
the fracture complexity increased.76 Finally, in a review
specically looking at referrals for complications, Jost
etal. discussed the importance of making the primary
surgery the denitive surgery. A majority of the patients
received arthroplasty as a revision surgery, secondary to
complicationsfromlockingplate. Inthesepatients,primary
reduction was not achieved, indicating that the more
complexfracturepatternsmay not necessarily be amenable
tolocking plate.77
None of the articles presented in this review were in
the most recent comprehensive systematic review, as
Sproul etal. completed their literature search in 2009.
In addition, none of the articles from the previous
systematicreviewsarein thisreviewasweonlyincluded
the most recent articles. We repeated our queries to
capture the most recent literature and data, noting
that there were quite a few articles we would not have
been able to include. More experience with locking
plate in treating proximal humerus fractures and the
application of newer techniques has denitely adjusted
complicationrates. Moreover,the complicationratesmay
not have been entirely accurate in the previous reviews
as they were analyzing a smaller number of total cases.
Thus, one of the aims of this review was to encompass
asmanyrecentarticleswithoutsacricingquality,which
we accomplished by including only high scoring articles
intothisstudy.
It is also worthwhile to discuss the fact that there is
a large amount of literature describing nonoperative
treatment of proximal humerus fractures. Concerning
Kavuri, et al.: Complications Associated with Locking Plate of Proximal Humerus Fractures
114 Indian Journal of Orthopaedics | Volume 52 | Issue 2 | March-April 2018
the number of complications as well as costs associated
with surgical treatment, there have also been studies
comparing operative versus nonoperative treatment of
these fractures. Handoll etal. found in their Proximal
Fracture of the Humerus: Evaluation by Randomization
trial that surgical treatment does not result in
improved outcomes in most patients and that it is not
cost effective.78 This lends support to the argument that
every fracture should be treated on a case-by-case basis.
Theosteoporoticnature of someofthesefractures leaves
it incredibly difcult to treat, and though locking plate
hasbeenpromising intheory,noteveryplateis the same
and cannot replicate force distributions of the proximal
humerus. The most used plate seemed to be the Synthes
PHILOS plate; however, not every article in our review
reported which plate they used. The design of the plate
cannot prevent varus collapse and subsequent cutout of
the screws. Biomechanical studies have shown this and
the importance of a medial buttress to prevent those
complications.79
There are a number of limitations to this review. First,
minimumfollowupwassetto12months, which may have
underestimated the incidence and prevalence of AVN. Not
every article commented on every complication analyzed
inthisreport.This could haveledtoeitherunder-reporting
or over reporting of results. Next, the heterogeneity of the
articles, whether it was based on level of evidence, type
offracture,approach,or specic technique used, could not
be fully accounted for. In addition, we did not perform a
metaanalysis of the complication rate. Our aim was to
provide a broad overview of complications with proposed
methods to decrease complication rate. A meta-analysis
wasnot ourgoalas wecannotequallycompareeachstudy,
such as comparing a three part fracture with a four-part
fracture. An attempt was made to highlight the most
important conclusions from each article. Finally, giving
moreweighttoarticleswith higher levels of evidence may
haveskewedthe resultsaswell.
Conclusion
The points of consideration from this review, in regard to
the major complications associated with locking plate in
proximalhumerus fractures, areasfollows:
Screw penetration
Greater care with uoroscopy, use of at least two
perpendicular planes to conrm screw is not within the
glenohumeral joint. Placement of screws that are too short
ofsubchondralbone shouldbeavoided.
Varus collapse
Ensure the medial column is intact (medial hinge).
Considerationoftheuseofstrutallograft,bonegraft,suture
augmentation,andplatecontouring.Considerplacementof
inferomedialsupport screws.
Subacromial impingement
Ensuretheplatedoesnotsittooproximally,AVN,Consider
fracture type to stratify risk of AVN, Careful soft-tissue
dissection,Considerminimally invasivetechniques.
Financial support and sponsorship
Nil.
Conicts of interest
Thereareno conictsofinterest.
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