Surgical Treatment of Proximal Humeral Fractures - Revision history

Alexandre.laedermann at 22:20, 27 January 2020

2020-01-27T22:20:16Z

Alexandre.laedermann at 21:30, 27 January 2020

2020-01-27T21:30:23Z

Show changes

Alexandre.laedermann: /* Arthroscopy */

2020-01-26T19:54:10Z

Arthroscopy

Alexandre.laedermann: /* Decision Making */

2020-01-07T21:15:59Z

Decision Making

Alexandre.laedermann: /* Decision Making */

2020-01-07T21:15:35Z

Decision Making

Alexandre.laedermann: /* Type II-IV cephalotubercular and bicipital groove fractures in the elderly */

2020-01-07T21:14:46Z

Type II-IV cephalotubercular and bicipital groove fractures in the elderly

Alexandre.laedermann: /* Decision Making */

2020-01-07T21:13:51Z

Decision Making

Alexandre.laedermann: /* Rehabilitation */

2020-01-07T21:12:23Z

Rehabilitation

Alexandre.laedermann: /* Reverse Shoulder Arthroplasty */

2020-01-07T21:11:38Z

Reverse Shoulder Arthroplasty

Alexandre.laedermann: /* Surgical technique */

2020-01-07T21:10:31Z

Surgical technique

← Older revision		Revision as of 22:20, 27 January 2020
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−	~~Written by Alexandre Lädermann~~
−
	==Bullet Points==		==Bullet Points==

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 '''''Arthroscopic treatment of a humeral head fracture.'''''
-[[File:1562909631408-lg.jpg|center|thumb|660x660px|''Figure 12. A) Anteroposterior radiograph and B) CT scan of the left shoulder, revealing a humeral head fracture. Six months after arthroscopic reduction without fixation, the Lamy frontal and lateral radiographs confirm a perfect reduction. The rotator cuff and tuberosities are intact, so secondary displacements are limited. Reproduce from Godeneche A, Freychet B, Gunst S, Daggett M, Viste A, Walch G. Arthroscopic Reduction of Acute Traumatic Posterior Glenohumeral Dislocation and Anatomic Neck Fracture Without Internal Fixation: 2-Year Follow-up. Orthop J Sports Med. 2017;5(12):2325967117745486, with permission.'']]
+[[File:1562909631408-lg.jpg|center|thumb|660x660px|''Figure 12. A) Anteroposterior radiograph and B) CT scan of the left shoulder, revealing a humeral head fracture. Six months after arthroscopic reduction without fixation, the Lamy frontal and lateral radiographs confirm a perfect reduction. The rotator cuff and tuberosities are intact, so secondary displacements are limited. Reproduce from <ref>Godeneche A, Freychet B, Gunst S, Daggett M, Viste A, Walch G. Arthroscopic Reduction of Acute Traumatic Posterior Glenohumeral Dislocation and Anatomic Neck Fracture Without Internal Fixation: 2-Year Follow-up. Orthop J Sports Med. 2017;5(12):2325967117745486</ref>, with permission.'']]
 ====Surgical technique====

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 ==Decision Making==
-Successful treatment depends on not only technical but also decision-making capabilities. Evidence confirming the best treatment for these fractures is lacking. However, it has recently been shown that the therapeutic consensus is directly correlated to the success of the surgery.
+Successful treatment depends on not only technical but also decision-making capabilities. Evidence confirming the best treatment for these fractures is lacking. However, it has recently been shown that the therapeutic consensus is directly correlated to the success of the surgery.<ref>Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. The Cochrane database of systematic reviews. 2015(11):CD000434.</ref><ref>LaMartina J, 2nd, Christmas KN, Simon P, Streit JJ, Allert JW, Clark J, et al. Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes. J Shoulder Elbow Surg. 2018;27(3):470-7.</ref>
 ===Humeral head fractures===

@@ Line 230: / Line 230: @@
 ==Decision Making==
 Successful treatment depends on not only technical but also decision-making capabilities. Evidence confirming the best treatment for these fractures is lacking. However, it has recently been shown that the therapeutic consensus is directly correlated to the success of the surgery.
 . Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. The Cochrane database of systematic reviews. 2015(11):CD000434.<ref>LaMartina J, 2nd, Christmas KN, Simon P, Streit JJ, Allert JW, Clark J, et al. Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes. J Shoulder Elbow Surg. 2018;27(3):470-7.</ref>
@@ Line 244: / Line 245: @@
 It seems reasonable to immediately resort to reverse shoulder arthroplasty in elderly patients having many comorbidities and lesser functional needs. A reverse implant seems all the more indicated when the displacement is large. The best treatment is osteosynthesis, then any conservative treatment, and lastly hemiarthroplasty. Osteosynthesis is the option having the most frequent revisions according to a recent meta-analysis.<ref>Du S, Ye J, Chen H, Li X, Lin Q. Interventions for Treating 3- or 4-part proximal humeral fractures in elderly patient: A network meta-analysis of randomized controlled trials. Int J Surg. 2017;48:240-6.</ref><ref>van der Merwe M, Boyle MJ, Frampton CMA, Ball CM. Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures. J Shoulder Elbow Surg. 2017;26(9):1539-45.</ref>
-=== Isolated sub-tubercular fractures ===
+===Isolated sub-tubercular fractures===
 Closed nailing or plate osteosynthesis are coeval. Plates are preferred in young patients to conserve their rotator cuff and facilitate their removal, and nails are used on older patients for whom removal of material is debatable. Fasciculated nailing are reserve for paediatric cases as it has not been proven in adults in comparative studies.<ref>Lee W, Park JY, Chun YM. Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration. J Orthop Trauma. 2017;31(9):e270-e4.</ref><ref>Milin L, Sirveaux F, Eloy F, Mainard D, Mole D, Coudane H. Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: retrospective study of 105 cases. Orthopaedics & traumatology, surgery & research : OTSR. 2014;100(3):265-70.</ref>
 ==References==
 <references />

@@ Line 244: / Line 244: @@
 It seems reasonable to immediately resort to reverse shoulder arthroplasty in elderly patients having many comorbidities and lesser functional needs. A reverse implant seems all the more indicated when the displacement is large. The best treatment is osteosynthesis, then any conservative treatment, and lastly hemiarthroplasty. Osteosynthesis is the option having the most frequent revisions according to a recent meta-analysis.<ref>Du S, Ye J, Chen H, Li X, Lin Q. Interventions for Treating 3- or 4-part proximal humeral fractures in elderly patient: A network meta-analysis of randomized controlled trials. Int J Surg. 2017;48:240-6.</ref><ref>van der Merwe M, Boyle MJ, Frampton CMA, Ball CM. Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures. J Shoulder Elbow Surg. 2017;26(9):1539-45.</ref>
-Isolated sub-tubercular fractures
+=== Isolated sub-tubercular fractures ===
 Closed nailing or plate osteosynthesis are coeval. Plates are preferred in young patients to conserve their rotator cuff and facilitate their removal, and nails are used on older patients for whom removal of material is debatable. Fasciculated nailing are reserve for paediatric cases as it has not been proven in adults in comparative studies.<ref>Lee W, Park JY, Chun YM. Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration. J Orthop Trauma. 2017;31(9):e270-e4.</ref><ref>Milin L, Sirveaux F, Eloy F, Mainard D, Mole D, Coudane H. Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: retrospective study of 105 cases. Orthopaedics & traumatology, surgery & research : OTSR. 2014;100(3):265-70.</ref>
-== References ==
+==References==
 <references />

@@ Line 213: / Line 213: @@
 Rehabilitation (or the absence thereof) after a proximal humerus fracture is crucial, and partly conditions the outcome.
-After surgery everything conspires to create a stiff shoulder: the patient’s fear, pain, hemarthrosis and periarticular hematoma, muscle contusion, capsular tear, bicipital tendinopathy, etc.. Ideally, the shoulder should be rehabilitated as soon as possible, depending on the stability of the osteosynthesis. Once mobility has been regained, we never recommend reinforcement, but rather a gradual and reasonable resumption of activity.
+After surgery everything conspires to create a stiff shoulder: the patient’s fear, pain, hemarthrosis and periarticular hematoma, muscle contusion, capsular tear, bicipital tendinopathy, etc.. Ideally, the shoulder should be rehabilitated as soon as possible, depending on the stability of the osteosynthesis. Once mobility has been regained, we never recommend reinforcement, but rather a gradual and reasonable resumption of activity.<ref>Charbonnier C, Lädermann A, Kevelham B, Chague S, Hoffmeyer P, Holzer N. Shoulder strengthening exercises adapted to specific shoulder pathologies can be selected using new simulation techniques: a pilot study. International journal of computer assisted radiology and surgery. 2017.</ref>
 In general, the hand, wrist and elbow should be actively mobilized as soon as possible.
 ===Stable Osteosynthesis===
-These are fixations obtained using antegrade intramedullary nailing or plates. Assisted active mobilization can be immediate. No immobilization is recommended. Physiotherapy is only intra-hospital the day after surgery to teach a rehabilitation protocol.
+These are fixations obtained using antegrade intramedullary nailing or plates. Assisted active mobilization can be immediate. No immobilization is recommended. Physiotherapy is only intra-hospital the day after surgery to teach a rehabilitation protocol.<ref>Liotard J. Painful shoulder rehabilitation: How to do it simple. Revue du rhumatisme monographies. 2010;77(3):239-45.</ref>
 ===Osteosynthesis with Relative Stability===
-This type of rehabilitation applies to osteosuture and screwing of the tuberosities. Early and aggressive rehabilitation can in fact be harmful by provoking secondary displacement. The patient is immobilized using a sling elbow at the side or neutral abduction-rotation pillow, depending on the tuberosities involved (lesser and greater, respectively). Passive mobilization is recommended, as short pendulum exercises repeated at least 5 times a day, elevation by self mobilization in the supine position, elbow stretched, with slow, highest possible elevations, and rotations with elbows bent at 90°, using a baton held in both hands, but only mobilized by the healthy upper limb.
+This type of rehabilitation applies to osteosuture and screwing of the tuberosities. Early and aggressive rehabilitation can in fact be harmful by provoking secondary displacement. The patient is immobilized using a sling elbow at the side or neutral abduction-rotation pillow, depending on the tuberosities involved (lesser and greater, respectively). Passive mobilization is recommended, as short pendulum exercises repeated at least 5 times a day, elevation by self mobilization in the supine position, elbow stretched, with slow, highest possible elevations, and rotations with elbows bent at 90°, using a baton held in both hands, but only mobilized by the healthy upper limb.<ref>Denard PJ, Lädermann A, Burkhart SS. Prevention and management of stiffness after arthroscopic rotator cuff repair: systematic review and implications for rotator cuff healing. Arthroscopy. 2011;27(6):842-8.</ref>
 ‘Dry’ physiotherapy or balneotherapy may be prescribed. It includes progress monitoring and correct performance of the exercises, patient motivation, relaxing massages of the scapular belt and passive mobilization exercises.

@@ Line 200: / Line 200: @@
 ==Reverse Shoulder Arthroplasty==
-In patients aged over 65, reverse implants are now more frequently performed than osteosynthesis and hemiarthroplasty. A systematic review of level I and II studies shows that reverse shoulder arthroplasty (RSA) grants better outcomes and is associated with fewer complications than hemiarthroplasty at short term follow-up.
+In patients aged over 65, reverse implants are now more frequently performed than osteosynthesis and hemiarthroplasty. A systematic review of level I and II studies shows that reverse shoulder arthroplasty (RSA) grants better outcomes and is associated with fewer complications than hemiarthroplasty at short term follow-up.<ref>Lädermann, A. Chiu, JC. Collin, P. Piotton, S. Nover, L. Scheibel, M. Hemi- vs reverse shoulder arthroplasty for acute proximal humeral fractures: a systematic review of level I and II studies. Obere Extremität. 2019</ref>
-. Lädermann, A. Chiu, JC. Collin, P. Piotton, S. Nover, L. Scheibel, M. Hemi- vs reverse shoulder arthroplasty for acute proximal humeral fractures: a systematic review of level I and II studies. Obere Extremität. 2019
+Effectively, for these elderly patients, with comorbidities and osteoporosis, hemiarthroplasty failure is a significant risk. While reverse shoulder arthroplasty does not rely as much on tuberosity healing, function proves to be higher when the tuberosities heal. Therefore, the tuberositis should be preserved and every effort should be made to achieve healing in the setting of reverse shoulder arthroplasty. Reverse shoulder arthroplasty is contraindicated in young and active patients, apart from exceptional lifesaving situations, and in cases of infection or when the axillary nerve is involved. In fact, except for partial mobility recovery, the complication rate remains high.<ref>Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg. 2013;22(9):1199-208.</ref>
 ====Surgical (Operative) Technique====
-Apart from time spent on the glenoid, implantation is in all respects similar to hemiarthroplasty. Exposure of the glenoid is easy given the absence of the proximal humerus. The glenoid cartilage is then removed using a curette and carefully milled by hand, given the absence of osteoarthritis. The glenoid baseplate should be placed so that the glenosphere is flush or slightly overhangs the lower edge of the glenoid (Figure 25) to avoid frictional impingements.
+Apart from time spent on the glenoid, implantation is in all respects similar to hemiarthroplasty. Exposure of the glenoid is easy given the absence of the proximal humerus. The glenoid cartilage is then removed using a curette and carefully milled by hand, given the absence of osteoarthritis. The glenoid baseplate should be placed so that the glenosphere is flush or slightly overhangs the lower edge of the glenoid (Figure 25) to avoid frictional impingements.<ref>Lädermann A, Gueorguiev B, Charbonnier C, Stimec BV, Fasel JH, Zderic I, et al. Scapular Notching on Kinematic Simulated Range of Motion After Reverse Shoulder Arthroplasty Is Not the Result of Impingement in Adduction. Medicine (Baltimore). 2015;94(38):e1615.</ref>
 One must be cognizant of the relationship between the baseplate and the selected glenosphere size. For instance, a 42 mm glenosphere will overlap a 25 mm baseplate by 8.5mm, whereas a 36 mm glenosphere will only overlap the baseplate by 5.5 mm. Thus, baseplate position may vary depending on baseplate diameter and glenosphere size. The glenosphere should preferably be neutral or only minimally lateralized. In our experience lateralized and inferior eccentric glenospheres are associated with lower rates of tuberosity healing (Unpublished data). The implant is then reduced and the tuberosities reinserted according to the technique described by Boileau et al. Higher rates of tuberosity healing have been reported with 135 degreesstems as opposed to 155 degrees stems, but no study has directly compared these to date.
 [[File:1562926812368-lg.jpg|center|thumb|700x700px|Figure 25. Frontal, axial and lateral Lamy radiographs after a reverse total shoulder implant. Note the lower positioning of the glenoid baseplate, the satisfactory reconstruction of the tuberosities, and the absence of cement at the autograft level.]]
 ==Rehabilitation==

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 The approach is most commonly deltopectoral. The joint is accessed by working through the fracture fragments in the setting of a 4-part fracture, or dividing the lesser and greater tuberosities in the setting of a 3-part fracture. The humeral head fragment is extracted. As with plate fixation, the rotator cuff is tagged with multiple sutures for subsequent fixation of the tuberosities.<ref>Collin P, Laubster E, Denard PJ, Akue FA, Lädermann A. The Nice knot as an improvement on current knot options: A mechanical analysis. Orthopaedics & traumatology, surgery & research : OTSR. 2016;102(3):293-6.</ref>
-Correct positioning of the implant and the tuberosities is an essential step, which will determine the quality of the functional result (cf above). The lateral offset is restored either by introducing a graft between the implant and the greater tuberosity if the implant does not fill the space, or by using a wide metaphyseal implant with no graft.
+Correct positioning of the implant and the tuberosities is an essential step, which will determine the quality of the functional result (cf above). The lateral offset is restored either by introducing a graft between the implant and the greater tuberosity if the implant does not fill the space, or by using a wide metaphyseal implant with no graft.<ref>White JJ, Soothill JR, Morgan M, Clark DI, Espag MP, Tambe AA. Outcomes for a large metaphyseal volume hemiarthroplasty in complex fractures of the proximal humerus. J Shoulder Elbow Surg. 2017;26(3):478-83.</ref>
-. White JJ, Soothill JR, Morgan M, Clark DI, Espag MP, Tambe AA. Outcomes for a large metaphyseal volume hemiarthroplasty in complex fractures of the proximal humerus. J Shoulder Elbow Surg. 2017;26(3):478-83.
+Height can be assessed fluoroscopically by restoring a Gothic arch appearance or by locating the insertion point of the pectoralis major.<ref>Krishnan SG, Bennion PW, Reineck JR, Burkhead WZ. Hemiarthroplasty for proximal humeral fracture: restoration of the Gothic arch. Orthop Clin North Am. 2008;39(4):441-50.</ref><ref>Kim BS, Kim DH, Song KS, Min BW, Bae KC, Cho CH. Is the pectoralis major tendon a reliable reference for restoration of humeral length with fracture hemiarthroplasty? J Shoulder Elbow Surg. 2018;27(2):e45-e9.</ref>
 In fact, the distance separating the upper edge of this tendon from the great tendon at the top of the humeral head is relatively constant (5.5 cm). With regard to the rotation of the implant, 20-30° retroversion (measured from a flexed elbow relative to the forearm) is normally recommended. This is 10° less than the anatomical retroversion, measured on the bi-epicondylar axis, taking into account the physiological valgus. Before implanting the final stem, a number 2.0 drill-hole is made at the metaphyseal level, through which two non-absorbable sutures are threaded to be used for fixation of the tuberosities in the vertical plane.
-The stems may be cemented or non-cemented. The cement mantle should not reach the tuberositis which could jeopardise their integration.
+The stems may be cemented or non-cemented. The cement mantle should not reach the tuberositis which could jeopardise their integration.<ref>Singh A, Padilla M, Nyberg EM, Chocas M, Anakwenze O, Mirzayan R, et al. Cement technique correlates with tuberosity healing in hemiarthroplasty for proximal humeral fracture. J Shoulder Elbow Surg. 2017;26(3):437-42.</ref>
-. Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. J Shoulder Elbow Surg. 2011;20(2 Suppl):S47-60.
+A “black and tan” technique is an effective method for ensuring this. The implant is reduced and the tuberosities are stabilized using Boileau’s technique.<ref>Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. J Shoulder Elbow Surg. 2011;20(2 Suppl):S47-60.</ref>
 ==Reverse Shoulder Arthroplasty==