Monoaxial versus polyaxial screw insertion in angular stable plate fixation of proximal humeral fractures: radiographic analysis of a prospective randomized study.
BACKGROUND
Monoaxial and polyaxial screw insertion are used in angular stable plating of displaced proximal humeral fractures. Aim of the study was to compare both fixation techniques by radiographic evaluation.


METHODS
Prospective randomized treatment with monoaxial or polyaxial screw insertion in angular stable anatomic preshaped plates of displaced proximal humeral fractures. Analysis of standardized true anterior-posterior (true a.p.) and outlet-view radiographs at 1 day, 6 weeks, 3 months, and 6 months after surgery by two radiologists with respect to radiographic evidence of secondary varus displacement, cut out of screws, osteonecrosis, and hardware failure. Secondary varus displacement was defined as a varus decrease of the humeral head-shaft angle of > 10 degree in true a.p. radiographs.


RESULTS
Sixty-six consecutive patients (48 women, [72.7%]; 18 men, [27.3%]; mean age 67.7 years [95% CI, 63.9-71.6]) with displaced proximal humeral fractures were evaluated in this study. Nineteen patients (29%) showed secondary varus displacement of > 10-degree angle. In 6 cases (9%), intra-articular cut out of screws was found. Furthermore, 1 case (2%) of nonunion was observed. No relationship between monoaxial and polyaxial screw insertion was found regarding occurrence of secondary varus displacement (monoaxial, 11/polyaxial, 8; p = 0.91) or screw cut out (monoaxial, 4/polyaxial, 2; p = 0.64). Prevalence of secondary varus displacement and hardware cut out was related to patients age (p = 0.02) and fracture pattern, according to Neer- and AO/OTA-classification (p < 0.001). The average immediate postoperative head-shaft angle was 135.2 degrees (CI, 132.3-138.1) in the group without radiographic complication, compared with 126.7-degree angle (CI, 123.6-129.7) among those with secondary varus displacement of > 10-degree angle and screw cut out (p < 0.001). Furthermore, in cases of an immediate postoperative head-shaft angle of < 130 degrees, there was a 48% incidence of secondary varus dislocation (n = 13) versus 15% in cases with a head-shaft angle > 130 degrees (n = 6, p = 0.004).


CONCLUSIONS
Monoaxial and polyaxial screw insertion allow for mechanical stabilization in angular stable plating of unstable proximal humerus fractures. Radiographic evidence of secondary varus displacement of > 10-degree angle and screw cut out was seen similarly often in both fixation techniques. To avoid secondary varus displacement and screw cut out, restoration of a humeral head-shaft angle of > 130 degrees seems to be important in monoaxial and polyaxial fixation of proximal humeral fractures.
Department of Trauma and Orthopaedic Surgery, Ludwig-Maximilians-University, Munich, Germany. Ben.Ockert@med.uni-muenchen.de
Ben
B
Ockert
Volker
V
Braunstein
Chlodwig
C
Kirchhoff
Markus
M
Körner
Sonja
S
Kirchhoff
Katharina
K
Kehr
Wolf
W
Mutschler
Peter
P
Biberthaler
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001860:Bone Plates; D016009:Chi-Square Distribution; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011446:Prospective Studies; D011859:Radiography; D012784:Shoulder Fractures / Q000000981:diagnostic imaging* / Q000601:surgery*; D018709:Statistics, Nonparametric; D016896:Treatment Outcome