Displaced proximal humeral fractures in elderly patients pose a challenge to treatment when associated with osteoporosis and comminution. Osteoporosis predispose to low energy fractures which often have a complex pattern [
14]. Poor bone quality makes screw purchase and fixation less secure [
6,
8]. The decreased healing capacity in osteoporosis is reflected in a dramatic increase in the rate of failure of implant fixation [
14,
15].
In present study, LPHP has shown encouraging results in displaced proximal humeral fractures in osteoporotic bones. Sound union was achieved in all patients. Secondary loss of reduction occurred in 4% patients after screw loosening in proximal fragment. Secondary varus deformity (head–shaft axis angle <120°) and retroversion of humeral head occurred in 14% patients in conventional plate osteosynthesis. Bone cement had been used to improve the holding power of screws in osteoporotic bones. Implant failure with screw loosening and secondary displacement of fracture fragments necessitated refixation of fracture in 4% patients [
3]. No revision surgery was performed in our study due to implant failure. LPHP was associated with significant lower risk of screw loosening and secondary loss of reduction as compared to conventional plates in the present series. LPHP offers the advantage of locking head screws, which enter the humeral head at various angles in order to maximise purchase [
14]. Fracture in a poor position is associated with poor functional results [
3,
5]. Malunion was mainly a hardware related problem. Insufficient fixation of the screws may cause partial loss of reduction with secondary displacement of the humeral head into varus position leading to unsatisfactory result. Whereas, a higher rate (12%) of varus malunion was observed in conventional plate osteosynthesis [
3]. We did not have any secondary varus deformity. However, fracture was fixed in varus primarily in 8% patients in our series and both these patients had moderate outcome. Primary malunion can be prevented if fracture is fixed in near anatomical position at the time of fixation. We feel that near anatomical reduction must be achieved before applying multidirectional screws, as plate does not help in reduction of proximal fragments. Rather it fixes the proximal fragments wherever they are. With varus malalignment, the plate must not be positioned too far cranially, otherwise there could be subacromial impingement which occurred in our two patients with varus malnion. Wanner et al. [
16] treated displaced proximal humerus fractures with open reduction and internal fixation with two one-third tubular plates on the anterior and lateral aspects of the proximal humerus. High stability, thus achieved, allowed early mobilization of the shoulder. Fixed angled devices, such as the angled blade plate, are very useful as they resist angular deformation and torsion [
14,
17]. However, Meier et al. [
18] did not recommend internal fixation with angled blade plate in unstable proximal humerus fractures due to high rate of complications (33%) including protrusion of blade into glenohumaral articulation (22%). Several authors showed satisfactory results with implants providing an angular stability [
9,
10,
19,
20]. Superficial infection rate of 4% in our series is comparable to 5% in series by Kaukakis et al. [
20]. Avascular necrosis of humerus has been reported to be 4–5% in other series [
9,
20]. Only AO/ASIF type-C fracture or Neer’s 4-part fracture had this complication. We did not include AO/ASIF type-C fracture or Neer’s 4-part fracture in our series. This may be the one of the reasons for non-occurrence of avascular necrosis in our series. Our results are comparable with other series using implants providing an angular stability with respect to union, subacromial impingement, secondary loss of reduction and varus malunion [
9,
20]. This suggests that LPHP is associated with satisfactory results in both osteoporotic and non-osteoporotic fractures of proximal humerus. Although small no of patients in our series is an limitation, higher rate of secondary loss of reduction (12.5%) was observed in fractures with severe osteoporosis (Singh index grade II) as compared to fractures with mild osteoporosis (0%) (Singh index grade IV). This suggests that there is need for further improvement in management of osteoporotic proximal humeral fractures.
The goal of surgical therapy is to obtain fracture reduction and stable fixation to enable immediate functional after treatment without the need for postoperative immobilization [
3]. The LPHP demonstrated superior biomechanical characteristics compared with the proximal humeral nail [
21]. Additional holes in the plate allow tension band fixation of the rotator cuff [
9,
14]. Stable construct allows early mobilization and satisfactory functional outcome. Use of LCP is recommended in elderly patients with osteoporotic bone [
9]. We are also of this view as elderly patients could attain an activity level that was sufficient to satisfy their needs regarding independent daily living. But, as expected, the mean Constant–Murley score declined with increasing age. It is because after achieving a satisfactory functional result with a good range of motion, elderly patients usually discontinue exercise at home and often lose range of motion. Author of this series has experience of open reduction and internal fixation on proximal humeral fractures and fracture dislocations using T-plate and bent semitubular plate (employed as a blade plate) in 1990 [
22]. Previous study had poor outcome in elderly patients. With the experience of both techniques, we have found locking proximal humeral plate an advantageous implant in communited 2-part fractures, 3-part fractures with osteoporosis in elderly patients. Fixed angular stability and meticulous rotator cuff repair leads to early mobilization and satisfactory functional outcome.