JOURNAL CLUB

Arthroplasty for Fractures Arthroplasty for Fractures of the Proximal part of the of the Proximal part of the Humerus.Humerus.

Dr.Jeya venkatesh MS(Orth)Dr.Jeya venkatesh MS(Orth) Dept of Orthopaedics,Dept of Orthopaedics, JPNATC, JPNATC, AIIMS, New Delhi.AIIMS, New Delhi.

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William Osler first introduced the concept of ‘Journal club’ in 1875

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David Dines- Ex President of the

American Shoulder and Elbow Society

Biomet Biomodular Total Shoulder System

Josua Dines James E. Voos

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Proximal humeral fractures account for 4% to

5% of all fractures

Complex Fractures? ORIF? Hemi? RSA

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Concomitant injuries Preinjury shoulder function

? Previous fracture? Previous rotator cuff deficiency? Severe osteoporosis

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AP Transscapular Y

View Axillary view

CT :Extensive comminution, displaced #

Full length view C/L humerus - Template

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NEER’S (>1cm displacement, >45˚ angulation ) AO HERTEL’S

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H

G

S

L

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Surgical technique:Surgical technique:

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Delto pectoral incision

Different Fibre orientationCephalic vein laterally

Axillary fold

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Keep Deltoid origin & insertion intact

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Incise fascia over biceps tendonIdentify the LHB

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Identify long head of biceps

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Separate & secure the tuberosities.

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Secure sutures in tendon bone interface

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Excision of fractured Humeral head

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Visualise the Glenoid

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Humeral canal is prepared by sequential reaming

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Anterolateral & posterolateral drill-holes

1 to 1.5 cm distal to the fracture

Sutures are placed through these holes prior to cementing

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Height of the component

pre op Templating

Intramedullary device

Measurements on device

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Effect of Incorrect Version

Too Anteverted Too Retroverted

Tuberosity healing compromised25

Closed reduction with trial headcomponent.

The head should translate 50% anteriorly, posteriorly, & inferiorly on the glenoid surface.

160˚ of forward elevation and stable internal & external rotation of the arm.

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Success of surgery =Success of surgery =Tuberosity reconstructionTuberosity reconstruction

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Bone grafting priorto tuberosity fixation

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The final humeral head component is placed after the sutures have been passed, and the tuberosity reconstruction commences.

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The greater tuberosity is secured to the shaft & the implant first, and this is followed by fixation of the lesser tuberosity.

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Vertical, Horizontal & Figure of eight sutures fix the tuberosities in position.

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Based security of the reconstruction.

0 to 6 weeks : Only Passive

> 6 wks : Active assisted exercises

8 to 12 weeks : Strengthening exercises

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Component malposition

Rotatorcuff failure

Periprosthetic fracture

Heterotopic ossification33

Good pain relief, but varying outcomes with regards to function, motion &strength.

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Bastian and Hertel : ORIF vs Hemisimilar functional results & patient satisfactionsimilar functional results & patient satisfaction. ORIF with preservation of the humeral head

should be considered when an adequate reduction and stable conditions for revascularization can be obtained.

Hemiarthroplasty is a viable alternative for patients with osteopenic bone and/or a comminuted fracture.

Bastian JD, Hertel R. Osteosynthesis and hemiarthroplastyof fractures of the proximal humerus:outcomes in a consecutive case series. J ShoulderElbow Surg. 2009;18:216-9

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Krishnan et al. : using ‘Gothic arch’ technique reported 88% of the tuberosities healed anatomically. The mean active mean active anterior elevation was 129˚, and pain scores anterior elevation was 129˚, and pain scores averaged 1.2 points on a 10-point scaleaveraged 1.2 points on a 10-point scale.

Krishnan SG, Bennion PW, Reineck JR, BurkheadWZ. Hemiarthroplasty for proximal humeral fracture:restoration of the Gothic arch. Orthop Clin North Am.2008;39:441-50,

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Boileau et al. described the ‘‘unhappy triad,’’ ‘‘unhappy triad,’’ in which a prosthesis has excessive height and retroversion and the greater tuberosity is positioned too low --> poor functional results, persistent pain & stiffness.

Boileau P, Walch G, Krishnan SG. Tuberosityosteosynthesis and hemiarthroplasty for four-partfractures of the proximal humerus. Tech ShoulderElbow Surg. 2000;1:96-109.

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AcuteAcute reconstruction (less than four weeksafter the injury) results in betterbetter functional outcomes because of the ease of tuberosity reconstruction

Dines DM, Warren RF. Modular shoulderhemiarthroplasty for acute fractures. Surgical considerations. Clin Orthop Relat Res. 1994;307:18-26.

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Bufquin et al. In RSA satisfactory mobility was RSA satisfactory mobility was obtained despite frequent migration of the obtained despite frequent migration of the tuberositiestuberosities, and they cautioned that an assessment of long-term results is required.

Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br. 2007;89:516-20.

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Descending order of Clinical successDescending order of Clinical success:

(1) Hemi in a patient with reconstructible tuberosities,

(2) RSA in a patient with reconstructible tuberosities,

(3) RSA in a patient without reconstructible tuberosities,

(4) Hemi in a patient without reconstructible tuberosities.

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Newer techniques to improve functional outcomes.

Long term multicentric randomised comparative study between RSA & Hemiarthroplasty.

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42THANK YOU