Skip to main content
SpringerLink
Log in

Parallel versus orthogonal plate osteosynthesis of adult distal humerus fractures: a meta-analysis of biomechanical studies

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

There are two widely used distal humerus fracture (DHF) fixation methods with either orthogonal or parallel double-plate osteosynthesis. However, biomechanical studies have shown inconsistent results on which technique is more effective. We performed a meta-analysis to compare these two fixation methods for adult DHF fixation.

Methods

We searched the literature for entries discussing the biomechanical testing of orthogonal and parallel fixation techniques for DHFs. We then performed a meta-analysis of the following biomechanical outcome measures: axial/sagittal/coronal/torsional stiffness, load to failure, and torque to failure.

Results

Seventeen studies comparing both constructs were included. The parallel configuration exhibited greater mechanical strength with respect to axial stiffness/load to failure, torsional stiffness, and posterior bending load to failure than the orthogonal constructs. Subgroup analysis revealed that parallel constructs also had higher torsional stiffness in supracondylar fractures.

Conclusions

This meta-analysis shows that parallel constructs provide greater axial stiffness, axial strength, and torsional stiffness than orthogonal plate for DHF fixation. A subgroup analysis revealed that parallel constructs had better torsional stiffness in supracondylar fracture fixation.

Level of evidence

IA

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Atalar AC, Tunalı O, Erşen A, Kapıcıoğlu M, Sağlam Y, Demirhan MS (2017) Biomechanical comparison of orthogonal versus parallel double plating systems in intraarticular distal humerus fractures. Acta Orthopaedica et Traumatologica Turcica 51:23–28. https://doi.org/10.1016/j.aott.2016.11.001

    Article  PubMed  Google Scholar 

  2. Caravaggi P, Laratta JL, Yoon RS, De Biasio J, Ingargiola M, Frank MA, Capo JT, Liporace FA (2014) Internal fixation of the distal humerus: a comprehensive biomechanical study evaluating current fixation techniques. J Orthop Trauma 28:222–226. https://doi.org/10.1097/BOT.0b013e3182a6693f

    Article  PubMed  Google Scholar 

  3. Flinkkilä T, Toimela J, Sirniö K, Leppilahti J (2014) Results of parallel plate fixation of comminuted intra-articular distal humeral fractures. J Shoulder Elb Surg 23:701–707. https://doi.org/10.1016/j.jse.2014.01.017

    Article  Google Scholar 

  4. Lee SK, Kim KJ, Park KH, Choy WS (2014) A comparison between orthogonal and parallel plating methods for distal humerus fractures: a prospective randomized trial. Eur J Orthop Surg Traumatol 24:1123–1131. https://doi.org/10.1007/s00590-013-1286-y

    Article  PubMed  Google Scholar 

  5. Ackerman G, Jupiter JB (1988) Non-union of fractures of the distal end of the humerus. J Bone Joint Surg Am 70:75–83. https://doi.org/10.2106/00004623-198870010-00012

    Article  CAS  PubMed  Google Scholar 

  6. Henley MB, Bone LB, Parker B (1987) Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma 1:24–35. https://doi.org/10.1097/00005131-198701010-00004

    Article  CAS  PubMed  Google Scholar 

  7. Kudo T, Hara A, Iwase H, Ichihara S, Nagao M, Maruyama Y, Kaneko K (2016) Biomechanical properties of orthogonal plate configuration versus parallel plate configuration using the same locking plate system for intra-articular distal humeral fractures under radial or ulnar column axial load. Injury 47:2071–2076. https://doi.org/10.1016/j.injury.2016.08.012

    Article  PubMed  Google Scholar 

  8. Zalavras CG, Vercillo MT, Jun BJ, Otarodifard K, Itamura JM, Lee TQ (2011) Biomechanical evaluation of parallel versus orthogonal plate fixation of intra-articular distal humerus fractures. J Shoulder Elb Surg 20:12–20. https://doi.org/10.1016/j.jse.2010.08.005

    Article  Google Scholar 

  9. Koonce RC, Baldini TH, Morgan SJ (2012) Are conventional reconstruction plates equivalent to precontoured locking plates for distal humerus fracture fixation? A biomechanics cadaver study. Clin Biomech (Bristol, Avon) 27:697–701. https://doi.org/10.1016/j.clinbiomech.2012.03.008

    Article  Google Scholar 

  10. Arnander MW, Reeves A, MacLeod IA, Pinto TM, Khaleel A (2008) A biomechanical comparison of plate configuration in distal humerus fractures. J Orthop Trauma 22:332–336. https://doi.org/10.1097/BOT.0b013e31816edbce

    Article  PubMed  Google Scholar 

  11. Hungerer S, Wipf F, von Oldenburg G, Augat P, Penzkofer R (2014) Complex distal humerus fractures-comparison of polyaxial locking and nonlocking screw configurations-a preliminary biomechanical study. J Orthop Trauma 28:130–136. https://doi.org/10.1097/BOT.0b013e31829d19a4

    Article  PubMed  Google Scholar 

  12. Korner J, Diederichs G, Arzdorf M, Lill H, Josten C, Schneider E, Linke B (2004) A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 18:286–293. https://doi.org/10.1097/00005131-200405000-00004

    Article  PubMed  Google Scholar 

  13. Tejwani NC, Murthy A, Park J, McLaurin TM, Egol KA, Kummer FJ (2009) Fixation of extra-articular distal humerus fractures using one locking plate versus two reconstruction plates: a laboratory study. J Trauma 66:795–799. https://doi.org/10.1097/TA.0b013e318181e53c

    Article  PubMed  Google Scholar 

  14. Cai H, Ni XH, Dong EL, Sheng GQ, Qin YX, Wang YH (2011) Load-strain-displacement of three patterns of dual-plate fixation for intercondylar fracture of the humerus. J Clin Rehabil Tissue Eng Res 15:4931–4935. https://doi.org/10.3969/j.issn.1673-8225.2011.26.045

    Article  Google Scholar 

  15. Jacobson SR, Glisson RR, Urbaniak JR (1997) Comparison of distal humerus fracture fixation: a biomechanical study. J South Orthop Assoc 6:241–249. https://doi.org/10.1016/S1058-2746(96)80076-0

    Article  CAS  PubMed  Google Scholar 

  16. Watson JD, Kim H, Becker EH, Shorofsky M, Lerman D, O'Toole RV, Eglseder WA, Murthi AM (2014) Are two plates necessary for extraarticular fractures of the distal humerus? Curr Orthop Pract 25:462–466. https://doi.org/10.1097/BCO.0000000000000144

    Article  Google Scholar 

  17. Scolaro JA, Hsu JE, Svach DJ, Mehta S (2014) Plate selection for fixation of extra-articular distal humerus fractures: a biomechanical comparison of three different implants. Injury 45:2040–2044. https://doi.org/10.1016/j.injury.2014.08.036

    Article  PubMed  Google Scholar 

  18. Shimamura Y, Nishida K, Imatani J, Noda T, Hashizume H, Ohtsuka A, Ozaki T (2010) Biomechanical evaluation of the fixation methods for transcondylar fracture of the humerus: ONI plate versus conventional plates and screws. Acta Med Okayama 64:115–120. https://doi.org/10.18926/AMO/3285

    Article  PubMed  Google Scholar 

  19. Doǧramaci Y, Esen E, Kürklü M, Kirici Y, Atahan AO, Kömürcü M (2010) Double plate osteosynthesis provides better biomechanical stabilization than double tension band technique in distal humerus fractures. Eklem Hastaliklari ve Cerrahisi 21:44–49

    PubMed  Google Scholar 

  20. Helfet DL, Hotchkiss RN (1990) Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma 4:260–264. https://doi.org/10.1097/00005131-199004030-00004

    Article  CAS  PubMed  Google Scholar 

  21. Reising K, Konstantinidis L, Helwig P, Wagner FC, Sudkamp NP, Strohm PC (2014) Minimally invasive stabilization of distal humerus fractures: a pilot study with biomechanical evaluation. Technol Health Care 22:909–913. https://doi.org/10.3233/thc-140864

    Article  CAS  PubMed  Google Scholar 

  22. Schemitsch EH, Tencer AF, Henley MB (1994) Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 8:468–475. https://doi.org/10.1097/00005131-199408060-00003

    Article  CAS  PubMed  Google Scholar 

  23. Fornasieri C, Staub C, Tourne Y, Rumelhart C, Saragaglia D (1997) [Biomechanical comparative study of three types of osteosynthesis in the treatment of supra and intercondylar fractures of the humerus in adults]. Etude biomecanique comparative de trois types d'osteosynthese pour les fractures sus et intercondyliennes de la palette humerale de l'adulte 83:237–242

  24. Kollias CM, Darcy SP, Reed JGR, Rosvold JM, Shrive NG, Hildebrand KA (2010) Distal humerus internal fixation: a biomechanical comparison of 90° and parallel constructs. Am J Orthop (Belle Mead, NJ) 39:440–444

    Google Scholar 

  25. Sanchez-Sotelo J, Torchia ME, O'Driscoll SW (2007) Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am 89:961–969. https://doi.org/10.2106/jbjs.e.01311

    Article  PubMed  Google Scholar 

  26. O’Driscoll SW (2005) Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 14:186s–194s. https://doi.org/10.1016/j.jse.2004.09.033

    Article  PubMed  Google Scholar 

  27. Tian D, Jing J, Qian JUN, Li J (2013) Comparison of two different double-plate fixation methods with olecranon osteotomy for intercondylar fractures of the distal humeri of young adults. Exp Ther Med 6:147–151. https://doi.org/10.3892/etm.2013.1102

    Article  PubMed  PubMed Central  Google Scholar 

  28. Shin SJ, Sohn HS, Do NH (2010) A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elb Surg 19:2–9. https://doi.org/10.1016/j.jse.2009.05.003

    Article  Google Scholar 

  29. Li BB, Lin F, Cai LH, Chen Y, Lin ZJ (2017) Meta analysis of parallel versus perpendicular double plating for distal humerus fracture of type C in adults. Zhonghua Wai Ke Za Zhi 55:626–631. https://doi.org/10.3760/cma.j.issn.0529-5815.2017.08.014

    Article  CAS  PubMed  Google Scholar 

  30. Schwartz A, Oka R, Odell T, Mahar A (2006) Biomechanical comparison of two different periarticular plating systems for stabilization of complex distal humerus fractures. Clin Biomech (Bristol, Avon) 21:950–955. https://doi.org/10.1016/j.clinbiomech.2006.04.018

    Article  Google Scholar 

  31. Schuster I, Korner J, Arzdorf M, Schwieger K, Diederichs G, Linke B (2008) Mechanical comparison in cadaver specimens of three different 90-degree double-plate osteosyntheses for simulated C2-type distal humerus fractures with varying bone densities. J Orthop Trauma 22:113–120. https://doi.org/10.1097/BOT.0b013e3181632cf8

    Article  PubMed  Google Scholar 

  32. Stoffel K, Cunneen S, Morgan R, Nicholls R, Stachowiak G (2008) Comparative stability of perpendicular versus parallel double-locking plating systems in osteoporotic comminuted distal humerus fractures. J Orthop Res 26:778–784. https://doi.org/10.1002/jor.20528

    Article  PubMed  Google Scholar 

  33. Penzkofer R, Hungerer S, Wipf F, von Oldenburg G, Augat P (2010) Anatomical plate configuration affects mechanical performance in distal humerus fractures. Clin Biomech (Bristol, Avon) 25:972–978. https://doi.org/10.1016/j.clinbiomech.2010.07.005

    Article  Google Scholar 

  34. Windolf M, Maza ER, Gueorguiev B, Braunstein V, Schwieger K (2010) Treatment of distal humeral fractures using conventional implants. Biomechanical evaluation of a new implant configuration. BMC Musculoskelet Disord 11:172. https://doi.org/10.1186/1471-2474-11-172

    Article  PubMed  PubMed Central  Google Scholar 

  35. Got C, Shuck J, Biercevicz A, Paller D, Mulcahey M, Zimmermann M, Blaine T, Green A (2012) Biomechanical comparison of parallel versus 90-90 plating of bicolumn distal humerus fractures with intra-articular comminution. J Hand Surg Am 37:2512–2518. https://doi.org/10.1016/j.jhsa.2012.08.042

    Article  PubMed  Google Scholar 

  36. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700. https://doi.org/10.1136/bmj.b2700

    Article  PubMed  PubMed Central  Google Scholar 

  37. Self J, Viegas SF, Buford WL Jr, Patterson RM (1995) A comparison of double-plate fixation methods for complex distal humerus fractures. J Shoulder Elb Surg 4:10–16

    Article  CAS  Google Scholar 

  38. Varady PA, von Ruden C, Greinwald M, Hungerer S, Patzold R, Augat P (2017) Biomechanical comparison of anatomical plating systems for comminuted distal humeral fractures. Int Orthop doi:https://doi.org/10.1007/s00264-017-3444-z

  39. Taylor PA, Owen JR, Benfield CP, Wayne JS, Boardman ND 3rd (2016) Parallel plating of simulated distal humerus fractures demonstrates increased stiffness relative to orthogonal plating with a distal humerus locking plate system. J Orthop Trauma 30:e118–e122. https://doi.org/10.1097/bot.0000000000000477

    Article  PubMed  Google Scholar 

  40. Celli A, Donini MT, Minervini C (2008) The use of pre-contoured plates in the treatment of C2–C3 fractures of the distal humerus: clinical experience. Chir Organi Mov 91:57–64. https://doi.org/10.1007/s12306-007-0022-3

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We would like to show our gratitude to Ka-Wai Tam for sharing his pearls of wisdom with us during the research course. We would also like to thank Chih-Kai Hong for his excellent assistance in collecting data for this meta-analysis.

Funding

No funding was received.

Author information

Authors and Affiliations

  1. Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Chien-An Shih, Wei-Ren Su, Wei-Chin Lin & Tai-Wei Tai

  2. Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan

    Chien-An Shih, Wei-Ren Su & Tai-Wei Tai

  3. Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan

    Chien-An Shih

  4. Medical Innovation Center, National Cheng Kung University, Tainan, Taiwan

    Wei-Ren Su

Authors
  1. Chien-An Shih
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wei-Ren Su
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Wei-Chin Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Tai-Wei Tai
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

CAS, WCL, WRS, and TWT: study conception and design

CAS and WCL: acquisition of data

CAS, WRS, WCL, TWT: analysis and interpretation of data

CAS and TWT: drafting of the article

All authors have read and approved the final submitted manuscript.

Corresponding author

Correspondence to Tai-Wei Tai.

Ethics declarations

Conflict of interest

None.

Additional information

None of the authors, their immediate family, nor any research foundation with which they are affiliated received financial payments or other benefits from any commercial entity related to the topic of this manuscript.

Electronic supplementary material

Table 1, S

Search strategy for this meta-analysis (DOC 20 kb)

Table 2, S

Quality of methodology (DOCX 15 kb)

ESM 1

(DOC 65 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shih, CA., Su, WR., Lin, WC. et al. Parallel versus orthogonal plate osteosynthesis of adult distal humerus fractures: a meta-analysis of biomechanical studies. International Orthopaedics (SICOT) 43, 449–460 (2019). https://doi.org/10.1007/s00264-018-3937-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-018-3937-4

Keywords

Search

Navigation