Fracture proximal humerus Fixation with K wires and External fixator
Proximal Humerus Fracture Proximal Humerus Fracture ...€¢Systematic Review- Namdari, et al. JBJS...
Transcript of Proximal Humerus Fracture Proximal Humerus Fracture ...€¢Systematic Review- Namdari, et al. JBJS...
HumeralHeadReplacementforFracture
ISAKOSSHANGHAI2017DanGuttmann,MD
DirectorofShoulder&ElbowSurgerySportsMedicineFellowshipTaosOrthopaedicInstitute
Asst.ProfessorUniversityofNewMexicoShoulderCommitteeISAKOS
TeamPhysicianUSSki&SnowboardTeam
TimothyJ.Lin,MD
SportsMedicineFellowshipTaosOrthopaedicInstituteSantaFe&Taos,NewMexicoUSA
ISAKOSSHANGHAI2017
DisclosureforDanGuttmannMD
Arthrex,PaciraConsultant
DisclosureforDanGuttmannMDandTimothyLinMD
Arthrex,Medacta,Tornier,Breg,DJO,S&N,StrykerInstitutional/FellowshipSupport
SantaFe&Taos,NewMexico
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Acknowledgement(scheduledtogivethistalk)
Leesa M. Galatz, MDMount Sinai Professor of Orthopedics
Leni and Peter May Department of Orthopedic SurgeryIcahn School of Medicine
Mount Sinai Health SystemNew York, NY
Proximal Humerus Fractures
• Challenge! – Technically difficult – Reconstruct normal anatomy – Faced w poor quality bone – Often comminuted fragments – Obtain Tuberosity healing – Restore Cuff function
Evolution of Treatment Concepts• ORIF
• Locking plates, deltoid splitting approach
• Percutaneous Pinning
• Limited indications • Applicable to certain
fracture types • Hemiarthroplasty
• Fracture specific prostheses
• Reverse for fracture
SevereProximalHumerusFractures Reasons Hemi Has a Role
1. Some reported outcomes equivalent 2. Reverse implants more expensive (relative) 3. Complications historically lower!!
• Risk value analysis- Superior outcomes with Reverse evolving • Related to developing technology/Implant design • Related to Surgeon Experience • Related to Patient factors/co-morbidities
HeadReplacementforFracture
• Goals-•Mustbedonecorrectly!!• Restoresofttissueanatomy–Restoreboneanatomy–TuberosityHealing–Fracturespecificstems
ProximalHumerusFracture ProximalHumerusFracture Tuberosity Reconstruction: Vertical Fixation
Is Reverse a Better Option?
• Main criticism- • Tuberosity healing • Solves the problem: • Immediate reconstruction • Stabilize shoulder • Don’t have to wait for
tuberosity healing
Hemiarthroplasty
• Failure of tuberosity healing • Common indication for
reverse TSA!
• Prominent humeral head • Superior instability • Pain!!
Reverse TSA Traditional Indications
• Fracture sequelae – Nonunion – Malunion – AVN – Tuberosity Osteotomy (Boileau, JBJS)
Reverse SR Indications Have expanded
Massive rotator cuff tears in elderlyFailed shoulder (hemi)arthroplasty/GlenoidAcute proximal humerus fractures in elderlyProximal humeral fracture sequelae: malunion & nonunion Risk of rotator cuff deficiency with arthritis Fatty substitution of SSP and ISP > grade 2B2 Glenoid eccentric wear /decenteringChronic dislocation/instabilityProximal humeral bone loss(tumor/trauma)
Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures
Van der Merwe M, Boyle MJ, Frampton CMA, Ball CM; JSES April 2017
Retrospective cohort study
From 1999 to 2014 218 patients underwent RSA and 427 underwent HHR for acute proximal humerus fractures, out of the New Zealand Joint registry records
Post-op outcomes at 6 months and 5 years post-op
Results: RSA pts older (78.2 vs 71.6 years), higher proportion female (90% vs 77%)
No significant difference in revision rate per 100 component-years (0.58 RSA vs 1.16 hemi, P=0.137), 1 year mortality (3.8% vs 3.4% P=0.805)
No difference in 6 month Oxford Shoulder Score (OSS) (29.6 vs. 28.4) or 5 year OSS (37.6 vs 32.7, P=0.078)
Conclusion – No significant difference in functional outcomes or revision rates between RSA and hemi for acute prox humerus fractures
Hemiarthroplasty versus Reverse shoulder arthroplasty:Comparative study of functional and radiological outcomes in the
treatment of acute proximal humerus fracture
Baudi, Campochiaro, Serafini et al.Musculoskeletal Surgery April 2014
Retrospective Cohort Study2008-2012 – 67 Patients treated with HHR or RSA
Evaluated 53 cases with avg follow-up of 27.5 months28 patients (mean age 71.4) treated with HHR
25 patients (mean age 77.3) treated with RSA
Constant, ASES, DASH score, Abduction Strength, ER1, ER2, and X-Rays
RSA HHR
Constant 56.2 42.3ASES 69.3 51.3
DASH 40.4 46.1
Abd Strength 4.3 1.3 lb inER1 3.3 3.7 lb in
ER2 3.2 1.8 lb in
Tuberosity healing rate
84% 37%
Results
Hemiarthroplasty versus reverse shoulder arthroplasty: comparative study of functional and radiological outcomes in
the treatment of acute proximal humerus fractureBaudi, Campochiaro, Serafini et al.
Musculoskeletal Surgery April 2014
ProximalHumerusFractures
37%(Hemi)vs.84%(RSA)tuberosityhealingrate
Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly
International Orthopaedics 2016; Savin, Zamfirova, Ianotti, et al
Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures
The survey also presented five representative cases to assess treatment preferences
205 surgeons responded (114 Shoulder and Elbow/35 Trauma/56 Sports/Other)
Preferred RSA for 4 part fractures in patients over age 65Trended to favor HHR with higher co-morbidities
Surgeons with >11 years of experience more likely to choose HHR for older/high comorbidity pts
RSA not preferred for younger/active patients
Shoulder Hemiarthroplasty for complex humeral fractures: A 5 to 10 year follow-up retrospective study
Musculoskeletal Surgery April 2014; Giovale, Mangano, Roda, Repetto et al.
27 Patients who had HHR btwn 2001 & 2005 for 3 & 4-part humeral Fxs
Evaluated at mean of 7.2 years post-opMean age at surgery was 71.9 years
Results: Implant survival 88.9%At latest f/u: Mean DASH 26.8; Mean SST-12: 6.5; Mean Constant-Murley: 52.4
Tuberosity complication rate and reduction in acromion-humeral distance were negatively related to clinical outcome
Conclusion: HHR outcomes show good results in majority of patients for complex humeral Fxs
Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty
JSES February 2014; Chalmers, Slikker, Mall, Gupta et al
Retrospective Cohort StudyProspectively evaluated patients who underwent RSA for displaced
3- & 4-part proximal humeral fractures
Created age and sex-matched control groups who underwent ORIF or HHR
Results: 27 patients; (9 RSA/9 HHR/9 ORIF); Minimum F/u 1 year
No significant differences in Simple Shoulder Test, ASES, SF-12 scores
More patients achieved > 90 degrees forward elevation after RSA RSA provided more significant cost savings compared with HHR and
ORIF
Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for Proximal Humeral Fractures: A Systematic Review
Journal of Orthopaedic Trauma Jan. 2015; Ferrel, Trinh, Fischer
Studies up until January 2014 reviewedStudies with outcomes reported on human subjects with
at least 1 year follow-up
Conclusions: RSA with better forward flexion 118 vs 108 in HHR
HHR with better ER 30 vs 20 in RSANo significant difference in either ASES (RSA 64.7 Hemi 63) or
Constant Score (RSA 54.6 Hemi 58)
RSA with higher rate of clinical complications (9.6%) but a lower revision rate (0.93%) compared with HHR
Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: The PROFHER Randomized Clinical Trial
JAMA 2015; Rangan, Handoll, Brealey, Jefferson et al
Multicenter RCT PROFHER group (Proximal Fracture of the Humerus Evaluation by Randomization) 32 Centers in UK from 2008-2011 within 3 weeks after proximal humerus Fx involving surgical neck
250 patients, mean age 66, range 24-92 (77% female/99.6% white
114 in surgical group and 117 nonsurgical group Surgery group: Either ORIF or HHR
Results:No significant difference in Oxford Shoulder Score
(39.07 surgical vs. 38.32 nonsurgical) at 2 years
No sig differences at 2 years in mean SF-12 physical component score, complications related to surgery or shoulder fracture requiring secondary surgery, mortality Conclusions: Overall no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years
Trends in Reverse TSA in US
• Reverse Shoulder Arthroplasty in the United States: A Comparison of National Volume, Patient Demographics, Complications, and Surgical Indications
• Westermann et al. Iowa Ortho Journal, 2015 • Epidemiological study of trends of reverse TSA in the US. • In 2011, 66K patients underwent shoulder arthroplasty • 22K were Reverse • 29K were conventional TSA • 15K were hemiarthroplasty
• Between 2002-2011, RSA and TSA increased, hemi decreased
Cost-Utility of RTSA for Proximal Humerus Fractures
• Hemi Arthroplasty Avg cost $7-8,000 • Reverse Avg cost $12-15,000
• Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: a cost-utility analysis
• Nwachukwu et al, JSES, May 2016 • Goal to compare non-op care, HA, and RTSA for proximal
humerus fractures • From payor perspective, RTSA was cost-effective with an
incremental cost-effectiveness ratio of $8100 per quality-adjusted life year
Complications• Bufquin (2007) • 5 neurologic injuries • 3 pain syndrome • 1 dislocation • 1 acromial fracture • 1 periprosthetic fx • 1 deltoid dehiscence
Complications
• Systematic Review- Namdari, et al. JBJS 2013 • 232 RTSA vs 263 Hemi • Outcome scores similar • 4x greater odds of having a complication • Nerve, pain syndrome, infection • Tuberosity malunion/nonunion, notching (89 vs 27%) • Dislocation • Equivalent reoperation rate
Complications
• In Both Hemi and Reverse • Dislocation • Loosening • Tuberosity migration • Superior migration
More common in Reverse • Scapular notching • Dislocation, Acromial Fx, Deltoid
injury
Neurologic injury after Reverse Bufquin-5/Lenarz-1/Reitman-3
Almost unheard of after a hemiarthroplasty
Results
• Hemiarthroplasty • results strongly dependent on
tuberosity healing • Greater ER • More patients with <90 elevation
• Reverse better than Hemi with failed tuberosity healing
Trend of Reverse for Fracture
• Hemi vs Reverse • Overall, results similar (if tuberosity healed) Often pts w poor bone quality • Hemi- results in 2 disparate groups • Reverse finds “middle ground” • Beware Complication Rate!!
ProximalHumerusFractures
• 504Hemiarthroplastiesvs.377RSAs• 3.6yrmeanfollow-up• ASES56vs.75• Forwardflexion21degreesgreaterRSA• Nodifferenceincomplicationrate
ProximalHumerusFractures
• New Zealand Joint Registry • 55 RSAs vs. 313 Hemi • 5 years results superior for RSA • No difference in revision
HHR and LHBT
Proximal humeral fractures treated with hemiarthroplasty:
Does tenodesis of the long head of the biceps improve results?
Soliman OA, Koptan WMT Injury 2013
RCT with 37 patients treated with HHR for 4-part fractures, fracture-dislocations, and head-split fractures
- LHB intact in 18 (Group 1)
- Tenodesis in 19 patients (Group 2) Constant Score
mean of 69.8 group 1
mean of 74.4 group 2
Shoulder pain affected 6 patients in group 1 (33%) and 3 patients in group 2 (15.8%)
Conclusions: Support routinely performing a tenodesis of the LHB during HHR
Issues to Consider
1. What is best for the patient? 2. What is most cost-effective? 3. What about magnitude of complications? Thank you!!