title: In vitro temperature evaluation during cement augmentation of proximal humerus plate screw tips.
abstract: BACKGROUND
  The treatment of proximal humerus fractures in patients with poor bone quality remains a challenge in trauma surgery. Augmentation with polymethylmethacrylate (PMMA) cement is a possible method to strengthen the implant anchorage in osteoporotic bone and to avoid loss of reduction and reduce the cut-out risk. The polymerisation of PMMA during cement setting leads, however, to an exothermic reaction and the development of supraphysiological temperatures may harm the bone and cartilage. This study addresses the issue of heat development during augmentation of subchondrally placed proximal humerus plate screws with PMMA and the possible risk of bone and cartilage necrosis and apoptosis.
  
  
  METHODS
  Seven fresh frozen humeri from geriatric female donors were instrumented with the proximal humerus interlocking system (PHILOS) plate and placed in a 37°C water bath. Thereafter, four proximal perforated screws were augmented with 0.5 ml PMMA each. During augmentation, the temperatures in the subchondral bone and on the articular surface were recorded with K-type thermocouples. The measured temperatures were compared to threshold values for necrosis and apoptosis of bone and cartilage reported in the literature.
  
  
  RESULTS
  The heat development was highest around the augmented tips of the perforated screws and diminished with growing distance from the cement cloud. The highest temperature recorded in the subchondral bone reached 43.5°C and the longest exposure time above 42°C was 86s. The highest temperature measured on the articular surface amounted to 38.6°C and the longest exposure time above 38°C was 5 min and 32s.
  
  
  CONCLUSIONS
  The study shows that augmentation of the proximal screws of the PHILOS plate with PMMA leads to a locally limited development of supraphysiological temperatures in the cement cloud and closely around it. The critical threshold values for necrosis and apoptosis of cartilage and subchondral bone reported in the literature, however, are not reached. In order to avoid cement extravasation, special care should be taken in detecting perforations or intra-articular cracks in the humeral head.
authors.affiliation: AO Research Institute, Davos, Switzerland. marek.blazejak@gmx.de
authors.forename: Marek
authors.initials: M
authors.lastname: Blazejak
authors.forename: Ladina
authors.initials: L
authors.lastname: Hofmann-Fliri
authors.forename: Lorenz
authors.initials: L
authors.lastname: Büchler
authors.forename: Boyko
authors.initials: B
authors.lastname: Gueorguiev
authors.forename: Markus
authors.initials: M
authors.lastname: Windolf
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017209:Apoptosis; D001696:Biomechanical Phenomena; D001843:Bone Cements / Q000627:therapeutic use*; D001863:Bone Screws; D002102:Cadaver; D005260:Female; D006801:Humans; D016268:Internal Fixators; D009336:Necrosis / Q000517:prevention & control; D019904:Polymethyl Methacrylate / Q000627:therapeutic use; D012784:Shoulder Fractures / Q000601:surgery*; D013696:Temperature
chemical_list: D001843:Bone Cements; D019904:Polymethyl Methacrylate
keywords: Cement; Humerus; Implant augmentation; PHILOS plate; PMMA; Thermal necrosis