Feasibility and Radiological Outcome of Minimally Invasive Locked Plating of Proximal Humeral Fractures in Geriatric Patients
Authors: Schuetze Konrad , Boehringer Alexander , Cintean Raffael , Gebhard Florian , Pankratz Carlos , Richter Peter Hinnerk , Schneider Michael , Eickhoff Alexander M. 
Published: November 2022

Background: Proximal humerus fractures are common injuries in the elderly. Locked plating showed high complication and reoperation rates at first. However, with second-generation implants and augmentation, minimally invasive locked plating might be a viable alternative to arthroplasty or conservative treatment. Material and Methods: A retrospective chart review was performed for all patients with proximal humerus fractures treated between 2014 and 2020 with locked plating. All patients over 60 years of age who underwent surgery for a proximal humerus fracture with plate osteosynthesis (NCB, Philos, or Philos with cement) during the specified period were included. Pathological fractures, intramedullary nailing, or arthroplasty were excluded. Primary outcome measurements included secondary displacement and surgical complications. Secondary outcomes comprised function and mortality within one year. Results: A total of 249 patients (mean age 75.6 +/− 8.9 years; 194 women and 55 men) were included in the study. No significant difference in the AO fracture classification could be found. Ninety-two patients were surgically treated with first-generation locked plating (NCB, Zimmer Biomet, Wayne Township, IN, USA), 113 patients with second-generation locked plating (Philos, Depuy Synthes, Wayne Township, IN, USA), and 44 patients with cement-augmented second-generation locked plating (Philos, Traumacem V+, Depuy Synthes). A 6-week radiological follow-up was completed for 189 patients. In all groups, X-rays were performed one day after surgery, and these showed no differences concerning the head shaft angle between the groups. The mean secondary varus dislocation (decrease of the head shaft angle) after six weeks for first-generation locked plating was 6.6 ± 12° (n = 72), for second-generation locked plating 4.4 ± 6.5 (n = 83), and for second-generation with augmentation 1.9 ± 3.7 (n = 35) with a significant difference between the groups (p = 0.012). Logistic regression showed a significant dependency for secondary dislocation for the type of treatment (p = 0.038), age (p = 0.01), and preoperative varus fracture displacement (p = 0.033). Significantly fewer surgical complications have been observed in the augmented second-generation locked plating group (NCB: 26.3%; Philos 21.5%; Philos-augmented 8.6%; p = 0.015). Range of motion was documented in 122 out of 209 patients after 3 months. In the Philos-augmented group, 50% of the patients achieved at least 90° anteversion and abduction, which was only about a third of the patients in the other 2 groups (NCB 34.8%, n = 46; Philos 35.8%, n = 56; augmented-Philos 50.0%, n = 20; p = 0.429). Conclusion: Minimally invasive locked plating is still a valuable treatment option for geriatric patients. With augmentation and modern implants, the complication rate is low and comparable to those of reverse shoulder arthroplasty reported in the literature, even in the challenging group of elderly patients.