The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Fluoroscopic Evaluation of Reduction and Plate Positioning in Proximal Humerus Fractures: A Case-Control Study Comparing CFR-PEEK and Metallic Plates

Document Type : RESEARCH PAPER

Authors
Gregorio Secci 1
Giovanni Galardi 1
Jacopo Corti 1
Matteo Innocenti 1
Luigi Zanna 2
Raffaele Tucci 3
1 University of Florence, School of Human Health Sciences, Largo Brambilla, Florence, Italy - Department of Orthopedic Surgery, AOU Careggi, University Hospital of Florence, Florence, Italy
2 Department of Orthopedic Surgery, Santa Maria Annunziata Hospital, ASL Toscana Centro - Via Antella, Bagno a Ripoli, Italy
3 Department of Orthopedic Surgery, AOU Careggi, University Hospital of Florence, Florence, Italy
10.22038/abjs.2025.87746.3970
Abstract
Objectives: Proximal humeral fractures (PHF) are common upper extremity injuries, particularly in older adults.  Recently, carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have gained popularity in trauma surgery due to their bone-like elasticity, radiolucency, and reduced risk of stress shielding. However, their impact on intraoperative fracture reduction and implant positioning remains unclear. The aim of our study was to assess CFR-PEEK plates’ impact on intraoperative fracture reduction and device positioning.
Methods: This retrospective case-control study evaluated PHFs treated with CFR-PEEK plates versus conventional metallic plates. Radiologic parameters, including plate-tuberosity distance, tuberosity-head distance, neck-shaft angle, neck-shaft distance, head-shaft angle, were assessed postoperatively. Thirty patients with CFR-PEEK plates were matched with a metal plate control group based on age, gender, and fracture type.
Results: The results showed no significant differences in fracture reduction quality between the two groups, suggesting CFR-PEEK plates allow comparable anatomical restoration. However, due to radiolucency and marker positioning, CFR-PEEK plates were more frequently placed too high.
Conclusion: In conclusion, CFR-PEEK plates provide effective fracture fixation comparable to metal plates but require careful positioning to avoid complications. Surgeons should take extra precautions to ensure proper plate positioning, using intraoperative guides rather than freehand techniques.
        Level of evidence: IV
Keywords
Carbon fiber-reinforced polyetheretherketone
CFR-PEEK
Fracture reduction
Impingement
Proximal humerus fracture
Radiolucency
Subjects
  1. Carbone S, Mezzoprete R, Papalia M, Arceri V, Carbone A, Gumina S. Radiographic patterns of osteoporotic proximal humerus fractures. Eur J Radiol. 2018;100:43-48. doi:10.1016/J.EJRAD.2017.12.025.
  2. Alrabaa RG, Ma G, Truong NM, et al. Trends in Surgical Treatment of Proximal Humeral Fractures and Analysis of Postoperative Complications over a Decade in 384,158 Patients. JBJS Open Access. 2022;7(4):e22.00008. doi:10.2106/JBJS.OA.22.00008.
  3. Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: A systematic review of treatment modalities. J Shoulder Elb Surg. 2008;17(1):42-54. doi:10.1016/J.JSE.2007.03.016.
  4. Egol KA, Ong CC, Walsh M, Jazrawi LM, Tejwani NC, Zuckerman JD. Early complications in proximal humerus fractures (OTA types 11) treated with locked plates. J Orthop Trauma. 2008;22(3):159-164. doi:10.1097/BOT.0b013e318169ef2a.
  5. Soerensen S, Larsen P, Korup LR, et al. Epidemiology of Distal Forearm Fracture: A Population-Based Study of 5426 Fractures. Hand (N Y). 2024;19(1):24-29. doi: 10.1177/15589447221109967.
  6. Innocenti M, Leggieri F, Secci G, Carulli C, Del Prete A, Civinini R. A dual telescoping lag screw nailing system for intertrochanteric fractures: retrospective analysis of clinical and radiologic outcomes. Eur J Orthop Surg Traumatol. 2024;34(4):2121-2128. doi:10.1007/s00590-024-03906-w.
  7. Leggieri F, Innocenti M, Franco P, et al. The interlocking lag screw design nail for pertrochanteric fracture: a systematic review of biomechanical studies using cadaveric specimens. Minerva. 2024;75(5):354-65.
  8. Lamb JN, Panteli M, Pneumaticos SG, Giannoudis PV. Epidemiology of pertrochanteric fractures: Our institutional experience. Eur J Trauma Emerg Surg. 2014;40(3):225-232. doi:10.1007/s00068-014-0375-x.
  9. Zanna L, Innocenti M, Secci G, Cipolleschi L, Carulli C, Civinini R. Acetabular Morphology Predicts the Risk of Dislocation Following Hemiarthroplasty for Femoral Neck Fractures in the Elderly. J Arthroplasty. 2023;38(9):1773-1778. doi:10.1016/j.arth.2023.02.042.
  10. Leino OK, Lehtimaki KK, Makela K, Äaarimaa V, Ekman E. Proximal humeral fractures in Finland: Trends in the incidence and methods of treatment between 1997 and 2019. Bone Joint J. 2022;104-B(1):150-156. doi: 10.1302/0301-620X.104B1.BJJ-2021-0987.R1.
  11. Voigt C, Geisler A, Hepp P, Schulz AP, Lill H. Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma. 2011;25(10):596-602. doi:10.1097/BOT.0B013E318206EB46.
  12. Dauwe J, Walters G, Holzer LA, Vanhaecht K, Nijs S. Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost. Int Orthop. 2020;44(6):1217-1221. doi:10.1007/S00264-020-04577-Y.
  13. Handoll H, Brealey S, Rangan A, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess. 2015;19(24):1-279. doi:10.3310/HTA19240.
  14. Martinez-Catalan N. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. Curr Rev Musculoskelet Med. 2023;16(2):75-84. doi:10.1007/S12178-022-09817-9/FIGURES/9.
  15. Fletcher JWA, Windolf M, Richards RG, Gueorguiev B, Buschbaum J, Varga P. Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations. J Orthop Res. 2019;37(4):957-964. doi:10.1002/jor.24235.
  16. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942. doi:10.1016/J.INJURY.2012.08.004.
  17. Secci G, Andrea G, Guarino A, et al. Is the critical shoulder angle a risk factor for symptomatic cuff tear after proximal humerus fracture treated with antegrade intramedullary bent nail?. Minerva. 2024;75(4):276-84.
  18. Lopiz Y, Garríguez-Pérez D, Martínez-Illán M, García-Fernández C, Marco F. Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications. Arch Orthop Trauma Surg. 2022;142(2):227-238. doi:10.1007/S00402-020-03678-Y.
  19. Lazzarini F, Distefano M, Shen T, et al. Anatomic Reduction of Greater Tuberosity Fragment for Shoulder Hemiarthroplasty: a Predictor of Good Clinical Outcome. Arch Bone Jt Surg. 2024;12(2):108-115. doi:10.22038/ABJS.2023.74441.3448.
  20. Valenti P, Aliani D, Maroun C, Werthel JD, Elkolti K. Shoulder hemiarthroplasty for proximal humeral fractures: analysis of clinical and radiographic outcomes at midterm follow-up: a series of 51 patients. Eur J Orthop Surg Traumatol. 2017;27(3):309-315. doi:10.1007/S00590-017-1927-7.
  21. Acevedo DC, VanBeek C, Lazarus MD, Williams GR, Abboud JA. Reverse shoulder arthroplasty for proximal humeral fractures: update on indications, technique, and results. J Shoulder Elb Surg. 2014;23(2):279-289. doi:10.1016/J.JSE.2013.10.003.
  22. Mouchantaf M, Parisi M, Secci G, et al. Optimizing range of motion in reverse shoulder arthroplasty the crucial role of glenoid inclination and lateralization. Bone Jt Open. 2024;5(10):851-857. doi: 10.1302/2633-1462.510.BJO-2024-0097.R1.
  23. Secci G, Mouchantaf M, Schippers P, et al. Outcomes of reverse shoulder arthroplasty in patients with os acromiale: a systematic review. InSeminars in Arthroplasty: JSES 2025. WB Saunders.
  24. Kavuri V, Bowden B, Kumar N, Cerynik D. Complications associated with locking plate of proximal humerus fractures. Indian J Orthop. 2018;52(2):108-116. doi: 10.4103/ortho.IJOrtho_243_17.
  25. Oldrini LM, Feltri P, Albanese J, Marbach F, Filardo G, Candrian C. PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis. Life (Basel, Switzerland). 2022;12(2). doi:10.3390/LIFE12020311.
  26. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J shoulder Elbow Surg. 2013;22(4):542-549. doi:10.1016/J.JSE.2012.06.008.
  27. Katthagen JC, Ellwein A, Lutz O, Voigt C, Lill H. Outcomes of proximal humeral fracture fixation with locked CFR-PEEK plating. Eur J Orthop Surg Traumatol. 2017;27(3):351-358. doi:10.1007/s00590-016-1891-7.
  28. Padolino A, Porcellini G, Guollo B, et al. Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes. Musculoskelet Surg. 2018;102(s1):49-56. doi:10.1007/s12306-018-0562-8.
  29. Sacchetti F, Andreani L, Palazzuolo M, et al. Carbon/PEEK nails: a case–control study of 22 cases. Eur J Orthop Surg Traumatol. 2020;30(4):643-651. doi: 10.1007/s00590-019-02602-4.
  30. Long JR, Kalani MA, Goulding KA, Ashman JB, Flug JA. Carbon-fiber-reinforced polyetheretherketone orthopedic implants in musculoskeletal and spinal tumors: imaging and clinical

 

        features. Skeletal Radiol. 2023;52(3):393-404. doi: 10.1007/s00256-022-04069-7.

  1. Ziegler P, Maier S, Stuby F, et al. Clinical Outcome of Carbon Fiber Reinforced Polyetheretherketone Plates in Patients with Proximal Humeral Fracture: One-Year Follow-Up. J Clin Med. 2023;12(21). doi:10.3390/jcm12216881.
  2. Rotini R, Cavaciocchi M, Fabbri D, et al. Proximal humeral fracture fixation: multicenter study with carbon fiber peek plate. Musculoskelet Surg. 2015:99 Suppl 1:S1-8.doi:10.1007/s12306-015-0371-2.
  3. Theivendran K, Arshad F, Hanif UK, Reito A, Griffin X, Foote CJ. Carbon fibre reinforced PEEK versus traditional metallic implants for orthopaedic trauma surgery: A systematic review. J Clin Orthop Trauma. 2021:23:101674. doi:10.1016/j.jcot.2021.101674.
  4. Hak DJ, Fader R, Baldini T, Chadayammuri VBS. Locking screw-plate interface stability in carbon-fibre reinforced polyetheretherketone proximal humerus plates. Int Orthop. 2017;41(9):1735-1739. doi:10.1007/s00264-017-3562-7.
  5. Ahrend MD, Kühle L, Riedmann S, Bahrs SD, Bahrs C, Ziegler P. Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures. Int Orthop. 2021;45(7):1845-1852. doi:10.1007/s00264-021-04945-2.
  6. Konrad G, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate: Surgical technique. J Bone Jt Surg. 2010:92 Suppl 1 Pt 1:85-95. doi:10.2106/JBJS.I.01462.
  7. Lazzarini F, Paoli T, Cozzi Lepri A, et al. Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study. Eur J Orthop Surg Traumatol. 2023;(3):1-9. doi: 10.1007/s00590-023-03690-z.
  8. Koh KH, Han KY, Yoon YC, Lee SW, Yoo JC. True anteroposterior (Grashey) view as a screening radiograph for further imaging study in rotator cuff tear. J Shoulder Elb Surg. 2013;22(7):901-907. doi:10.1016/J.JSE.2012.09.015.
  9. Schippers P, Lacouture JD, Junker M, et al. Can we separately measure glenoid vs. humeral lateralization and distalization in reverse shoulder arthroplasty? J Shoulder Elb Surg. 2024;33(5):1169-1176. doi:10.1016/J.JSE.2023.09.026.
  10. Schippers P, Meurer A, Schnetz M, et al. A Novel Tool for Collaborative and Blinded Orthopedic Image Analysis. Life (Basel). 2023;13(9):1805. doi: 10.3390/life13091805.5.
  11. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. 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.
  12. Labronici PJ, e Albuquerque RP, Schott V, Pires RES, Belangero WD, Franco JS. Proximal humeral fractures: an understanding of the ideal plate positioning. Int Orthop. 2014;38(10):2191-2195. doi:10.1007/s00264-014-2463-2.
  13. Sheng N, Shi T, Wang Q, Wang L, Chen Y. Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study. J Orthop Surg Res. 2023;18(1). doi:10.1186/S13018-023-03811-8.
  14. Greiner S, Kääb MJ, Haas NP, Bail HJ. Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures. Injury. 2009;40(2):186-191. doi:10.1016/J.INJURY.2008.05.030.
  15. Dheenadhayalan J, Prasad VD, Devendra A, Rajasekaran S. Correlation of radiological parameters to functional outcome in complex proximal humerus fracture fixation: A study of 127 cases. J Orthop Surg (Hong Kong). 2019;27(2):2309499019848166. doi: 10.1177/2309499019848166.
  16. Mathur B, Suriyakumar S, Manickam K, Sameer M, Harshvardhan JKG. Correlation of radiological parameters with functional outcomes post fixation with proximal humerus locking plates. Int Orthop. 2024;48(12):3207-3216. doi: 10.1007/s00264-024-06324-z.
  17. 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.
  18. Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int. 2005:16 Suppl 2:S65-72. doi:10.1007/s00198-004-1714-2.
  19. Fletcher JWA, Windolf M, Richards RG, Gueorguiev B, Buschbaum J, Varga P. Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations. J Orthop Res. 2019;37(4):957-964. doi:10.1002/JOR.24235.
  20. Jung SW, Shim SB, Kim HM, Lee JH, Lim HS. Factors that influence reduction loss in proximal humerus fracture surgery. J Orthop Trauma. 2015;29(6):276-282. doi: 10.1097/BOT.0000000000000252.
  21. Bai L, Fu Z, An S, Zhang P, Zhang D, Jiang B. Effect of calcar screw use in surgical neck fractures of the proximal humerus with unstable medial support: A biomechanical study. J Orthop Trauma. 2014;28(8):452-457. doi: 10.1097/BOT.0000000000000057.
  22. Kimmeyer M, Schmalzl J, Rentschler V, et al. Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws. J Orthop Traumatol. 2023;24(1). doi:10.1186/s10195-023-00733-3.
  23. Königshausen M, Kübler L, Godry H, Citak M, Schildhauer TA, Seybold D. Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system? Injury. 2012;43(2):223-231. doi:10.1016/J.INJURY.2011.09.024.
  24. Ockert B, Pedersen V, Geyer L, Wirth S, Mutschler W, Grote S. Position of polyaxial versus monoaxial screws in locked plating for proximal humeral fractures: Analysis of a prospective randomized study. Eur J Orthop Surg Traumatol. 2014;24(5):747-752. doi: 10.1007/s00590-013-1360-5.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 14, Issue 2
February 2026
Pages 121-128

  • Receive Date 29 April 2025
  • Revise Date 13 May 2025
  • Accept Date 22 July 2025