Assessment of using thread joysticks results for fragment reduction and bone allografting in the treatment of bone defects in patients with proximal humeral fractures

Introduction Despite significant advances in the development of new fixation systems and improvements in surgical technologies, algorithms that guarantee anatomical reduction in proximal humerus fractures are lacking.
The aim of this study was to evaluate the clinical efficacy of using thread joysticks for fragment reduction and allogeneic bone grafting materials to repair bone defects in patients with proximal humerus fractures.
Material and methods A total of 219 patients with proximal humerus fractures were treated. The main group consisted of 123 patients and was treated according to the proposed by us osteosynthesis, while the comparison group included 96 patients was managed with traditional methods. Long-term outcomes were assessed at 1 to 4 years postoperatively using the Constant score, as well as two questionnaires: the Simple Shoulder Test (SST) and the Oxford Shoulder Score (OSS).
Results In the main group, the Constant score ranged from a maximum of 98 to a minimum of 6, with a mean of 69.8 and a median of 73. In the control group, the maximum score was 93, the minimum was 8, with a mean and  median of 54. Poor results were observed in 9 patients (7.3 %) in the main group. Of these, 4 (3.3 %) were due to infection, 3 (2.4 %) to implant migration, and 2 (1.6 %) to poor compliance with rehabilitation, leading to shoulder joint contracture. In the comparison group, 32 patients (33.3 %) had poor outcomes. Among them, 15 (15.6 %) had persistent limitations in abduction and internal rotation, 10 (10.4 %) exhibited implant migration, 5 (5.2 %) developed infection requiring reoperation, and 2 (2.1 %) experienced severe post‑traumatic arthritis and humeral head collapse.
Discussion The described technique has a number of advantages compared toexisting methods, which allows for  stable fixation in cases of 3- and 4-part fractures and avoids the need for shoulder joint replacement. It  features a clearly defined algorithm of procedures that simplifies the reduction and fixation of bone fragments, especially in defects of the proximal humerus.
Conclusion The application of this surgical technique reduced operative time and improved treatment outcomes in fractures of the proximal humerus.

1. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87-92. doi: 10.1097/01.blo.0000194672.79634.78.

2. Song JQ, Deng XF, Wang YM, et al. Operative vs. nonoperative treatment for comminuted proximal humeral fractures in elderly patients: a current meta-analysis. Acta Orthop Traumatol Turc. 2015;49(4):345-353. doi: 10.3944/AOTT.2015.14.0451.

3. Handoll HH, Elliott J, Thillemann TM, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022;6(6):CD000434. doi: 10.1002/14651858.CD000434.pub5.

4. Burkhart KJ, Dietz SO, Bastian L, et al. The treatment of proximal humeral fracture in adults. Dtsch Arztebl Int. 2013;110(35-36):591-597. doi: 10.3238/arztebl.2013.0591.

5. Tamimi I, Montesa G, Collado F, et al. Displaced proximal humeral fractures: when is surgery necessary? Injury. 2015;46(10):1921-1929. doi: 10.1016/j.injury.2015.05.049.

6. Magovern B, Ramsey ML. Percutaneous fixation of proximal humerus fractures. Orthop Clin North Am. 2008;39(4):405-416. doi: 10.1016/j.ocl.2008.05.005.

7. Siebenbürger G, Van Delden D, Helfen T, et al. Timing of surgery for open reduction and internal fixation of displaced proximal humeral fractures. Injury. 2015;46 Suppl 4:S58-62. doi: 10.1016/S0020-1383(15)30019-X.

8. Boudard G, Pomares G, Milin L, et al. Locking plate fixation versus antegrade nailing of 3- and 4-part proximal humerus fractures in patients without osteoporosis. Comparative retrospective study of 63 cases. Orthop Traumatol Surg Res. 2014;100(8):917-924. doi: 10.1016/j.otsr.2014.09.021.

9. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91(6):1320-1328. doi: 10.2106/JBJS.H.00006.

10. Lekic N, Montero NM, Takemoto RC, et al. Treatment of two-part proximal humerus fractures: intramedullary nail compared to locked plating. HSS J. 2012;8(2):86-91. doi: 10.1007/s11420-012-9274-z.

11. Schulte LM, Matteini LE, Neviaser RJ. Proximal periarticular locking plates in proximal humeral fractures: functional outcomes. J Shoulder Elbow Surg. 2011;20(8):1234-1240. doi: 10.1016/j.jse.2010.12.015.

12. Agudelo J1, Schürmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681. doi: 10.1097/BOT.0b013e31815bb09d.

13. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427-433. doi: 10.1016/j.jse.2004.01.034.

14. Vaza AYu, Fayn AM, Ivanov PA, et al. Analysis of the application of different bone grafting procedures in patients with intra-articular fractures. The Russian Journal of Transplantation. 2015;(4):6-12.

15. Chen H, Yin P, Wang S, et al. The Augment of the Stability in Locking Compression Plate with Intramedullary Fibular Allograft for Proximal Humerus Fractures in Elderly People. Biomed Res Int. 2018;2018:3130625. doi: 10.1155/2018/3130625.

16. Davids S, Allen D, Desarno M, et al. Comparison of Locked Plating of Varus Displaced Proximal Humeral Fractures With and Without Fibula Allograft Augmentation. J Orthop Trauma. 2020;34(4):186-192. doi: 10.1097/BOT.0000000000001679.

17. Biermann N, Prall WC, Böcker W, et al. Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies. Arch Orthop Trauma Surg. 2019;139(8):1075-1099. doi: 10.1007/s00402-019-03162-2.

18. Panchal K, Jeong JJ, Park SE, et al. Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft. Int Orthop. 2016;40(3):569-577. doi: 10.1007/s00264-015-2950-0.

19. Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2015;24(12):1968-1973. doi: 10.1016/j.jse.2015.06.028.

20. Burkhart KJ, Dietz SO, Bastian L, et al. The treatment of proximal humeral fracture in adults. Dtsch Arztebl Int. 2013 ;110(35-36):591-597. doi: 10.3238/arztebl.2013.0591.

21. Besch L, Daniels-Wredenhagen M, Mueller M, et al. Hemiarthroplasty of the shoulder after four-part fracture of the humeral head: a long-term analysis of 34 cases. J Trauma. 2009;66(1):211-214. doi: 10.1097/TA.0b013e31815d9649.

22. Lanzetti RM, Gaj E, Berlinberg EJ, et al. Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years. Clin Orthop Relat Res. 2023;481(4):735-747. doi: 10.1097/CORR.0000000000002480.

23. Suroto H, De Vega B, Deapsari F, et al. Reverse total shoulder arthroplasty (RTSA) versus open reduction and internal fixation (ORIF) for displaced three-part or four-part proximal humeral fractures: a systematic review and metaanalysis. EFORT Open Rev. 2021;6(10):941-955. doi: 10.1302/2058-5241.6.210049.

24. Foruria AM. Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement. Curr Rev Musculoskelet Med. 2023;16(10):457-469. doi: 10.1007/s12178-023-09853-z.

25. Patel AH, Wilder JH, Ofa SA, et al. Trending a decade of proximal humerus fracture management in older adults. JSES Int. 2021;6(1):137-143. doi: 10.1016/j.jseint.2021.08.006.

26. Baker HP, Gutbrod J, Strelzow JA, et al. Management of Proximal Humerus Fractures in Adults-A Scoping Review. J Clin Med. 2022;11(20):6140. doi: 10.3390/jcm11206140.

27. Titov RS, Fain AM, Vaza AYu, et al. Method for plastic surgery of bone defects of the humeral head in posterior blocked dislocations of the humerus. Patent RF, no. 2831905. 2024. Available at: https://www.fips.ru/registers-doc-view/fips_servlet?DB=RUPAT&DocNumber=2831905&TypeFile=html. Accessed Jul 24, 2025. (In Russ.)

28. Nho SJ, Brophy RH, Barker JU, et al. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007;15(1):12-26. doi: 10.5435/00124635-200701000-00003.

29. Crosby LA, Neviaser RJ. Proximal humerus fractures: Evaluation and management. Springer; 2015:99-105. doi: 10.1007/978-3-319-08951-5.

30. Thelen S, Grassmann JP, Schneider M, et al. The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures. GMS Interdiscip Plast Reconstr Surg DGPW. 2022;11:Doc03. doi: 10.3205/iprs000164.

31. Fu H, Wu J, Wu X. Intramedullary Nail for Treatment of Proximal Humeral Fracture: A Credible Fixation in Comminuted Calcar. Orthop Surg. 2023;15(8):2007-2015. doi: 10.1111/os.13616.