Clinical and radiological assessment of iliac crest autograft augmentation in three- and four-part proximal humerus fractures

Abstract

Aims: To evaluate the clinical and radiological outcomes of locking plate fixation with versus without intramedullary iliac crest cortical autograft augmentation in patients with three- and four-part proximal humerus fractures or fracture-dislocations, particularly in the context of osteoporotic bone and medial calcar insufficiency. Methods: This retrospective study included 65 patients aged between 18 and 65 years treated for complex proximal humerus fractures at a single tertiary institution between 2015 and 2023. Patients were divided into two groups: those treated with locking plate fixation alone (n=47) and those treated with locking plate fixation combined with intramedullary iliac crest autograft augmentation (n=18). Functional outcomes were evaluated using range of motion (ROM), Constant-Murley shoulder outcome score, and Visual Analog Scale (VAS) for pain at 12 months postoperatively. Radiological healing was assessed by time to union. Statistical analyses included t-tests, ANOVA, and Fisher’s exact test, with a p-value <0.05 considered statistically significant. Results: Patients receiving iliac crest grafts (plate+graft group) demonstrated significantly improved union time and greater ROM in flexion, extension, and abduction compared to the Plate-only group (all p<0.001). However, there were no statistically significant differences between the groups in adduction, internal rotation, external rotation, Constant-Murley scores, or VAS pain scores (p>0.05). The mean age of patients was higher in the graft group (49.2 vs. 42.5 years; p<0.001), but this did not alter the functional outcome trends. Conclusion: Iliac crest cortical autograft augmentation in locking plate fixation of complex proximal humerus fractures offers significant biomechanical advantages, including shorter union time and enhanced shoulder mobility in specific planes. Despite these radiological and kinematic benefits, the absence of significant differences in patient-reported outcomes suggests a functional ceiling effect, where improvements in structural stability do not necessarily correlate with perceived clinical benefit. These findings support the selective use of autografts, particularly in fractures with medial calcar deficiency, while also emphasizing the need for individualized rehabilitation protocols and longer-term follow-up to determine the full clinical value of graft augmentation.

Keywords

• Proximal humerus fracture
• Constant-Murley shoulder outcome score
• iliac crest autograft
• plate fixation

Üç veya dört parçalı proksimal humerus kırıklarında iliak krest otogreft augmentasyonunun klinik ve radyolojik değerlendirmesi

Abstract

Amaç: Osteoporotik kemik ve medial calcar yetersizliği bağlamında, üç ve dört parçalı proksimal humerus kırıkları veya kırıklı çıkıklarında intramedüller iliak krista kortikal otogreft augmentasyonu ile birlikte veya sadece kilitli plak fiksasyonu yapılan hastaların klinik ve radyolojik sonuçlarını değerlendirmek. Yöntemler: Bu retrospektif çalışma, 2015–2023 yılları arasında tek bir üçüncü basamak sağlık kurumunda kompleks proksimal humerus kırığı nedeniyle tedavi edilen, yaşları 18 ile 65 arasında değişen 65 hastayı kapsamaktadır. Hastalar iki gruba ayrıldı: yalnızca kilitli plakla tedavi edilenler (n=47) ve kilitli plakla birlikte intramedüller iliak krista otogreft augmentasyonu yapılanlar (n=18). Fonksiyonel sonuçlar; hareket açıklığı (ROM), Constant-Murley Omuz Skoru ve ameliyattan 12 ay sonra Görsel Analog Skala (VAS) ile ağrı değerlendirmesi kullanılarak ölçüldü. Radyolojik iyileşme, kaynama süresi ile değerlendirildi. İstatistiksel analizlerde t-testi, ANOVA ve Fisher’ın kesin testi kullanıldı; p < 0.05 anlamlı kabul edildi. Bulgular:İliak krista grefti uygulanan hastalar (Plak+Greft grubu), yalnızca plak kullanılan gruba göre anlamlı derecede daha kısa kaynama süresi ve fleksiyon, ekstansiyon ve abduksiyon hareketlerinde daha geniş hareket açıklığı gösterdi (tümü için p < 0.001). Ancak, adduksiyon, internal rotasyon, eksternal rotasyon, Constant-Murley skorları ve VAS ağrı skorlarında gruplar arasında anlamlı fark bulunmadı (p > 0.05). Greft grubundaki hastaların yaş ortalaması daha yüksekti (49.2 vs. 42.5 yıl; p < 0.001), ancak bu durum fonksiyonel sonuç eğilimlerini değiştirmedi. Sonuç:Kompleks proksimal humerus kırıklarının kilitli plak fiksasyonunda iliak krista kortikal otogreft augmentasyonu, daha kısa kaynama süresi ve belirli hareket düzlemlerinde omuz mobilitesinde artış gibi önemli biyomekanik avantajlar sağlar. Bununla birlikte, hasta tarafından bildirilen sonuçlarda anlamlı fark olmaması, yapısal stabilitedeki iyileşmenin klinik algıya her zaman yansımayabileceğini (fonksiyonel tavan etkisi) göstermektedir. Bu bulgular, özellikle medial calcar yetersizliği olan kırıklarda otogreftlerin seçici kullanımını desteklerken, bireyselleştirilmiş rehabilitasyon protokollerine ve greft augmentasyonunun tam klinik değerini belirlemek için uzun dönemli izleme gereksinimine dikkat çekmektedir.

Keywords

• Proksimal humerus kırığı
• Constant-Murley Omuz Sonuç Skoru
• İliak krest otogreft
• Plak fiksasyonu

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