This article is more than 5 years old. Information may no longer be current.
Experts compare options in managing proximal humeral fractures operatively
Humeral locking plates change indications for how many surgeons tackle ORIF vs. hemiarthroplasty.
The operative management of proximal humerus fractures remains a challenge for orthopedic surgeons. Although over 80% of these fractures are minimally displaced and can be treated nonoperatively, displaced fractures generally require operative management. Surgical options include internal fixation, using a variety of devices, to hemiarthroplasty using implants specifically designed for fracture. The advent of locking-plate technology and its use for proximal humerus fractures has also provided us with a valuable option for internal fixation.
We are fortunate to have four well-known and highly experienced shoulder specialists/fracture surgeons join us for this Virtual Roundtable discussion.
Joseph D. Zuckerman, MD
Moderator
| ||||||||
Joseph D. Zuckerman, MD
Wayne Z. Burkhead Jr., MD
Kenneth A. Egol, MD
Andrew Green, MD
Thomas Wright, MDJoseph D. Zuckerman, MD: Has the locking plate changed your indications for open reduction and internal fixation (ORIF) of 3- and 4-part proximal humeral fractures?
Andrew Green, MD: Although locking plates have not changed my indications for ORIF of displaced proximal humerus fractures, they have added an internal fixation option in some cases that I think substantially improves my ability to achieve stable internal fixation. This is particularly true in fractures with surgical neck comminution, especially calcar fractures that have inherent axial instability. This, in turn, has reduced the risk of loss of fixation and facilitated earlier initiation of range of motion in the postoperative rehabilitation in these cases.
Locking plates are also a substantial improvement over previous plate and screw fixation options in patients with osteopenia.
Nevertheless, I still frequently use heavy suture internal fixation for many three-part fractures in older patients when the surgical neck is not comminuted.
Kenneth A. Egol, MD: Yes, the locking plate has changed my indications. I have been more aggressive in fixing three- and four-part fractures. In fact, over the past 2½ years, I have not performed a single proximal humeral replacement for a fracture.
|
Certainly, while no implant is a panacea for difficult fracture patterns, I believe the locking plate is ideally suited for treating fractures of the proximal humerus. More so than any other implant, the proximal humerus locking plate allows for precise restoration of proximal humeral anatomy.
Thomas Wright, MD: The humeral locking plate has been a significant advance in the fixation of more complex proximal humerus fractures. It allows for a systematic approach of indirect reduction, placement of a pin in the center of the head and then placement of the locked screws. However, it is not only the locked screws that are of importance. Most of the plates allow sutures, which are passed through the cuff to be readily incorporated into the plating construct. It is the combination of the locked screws and the tension band effect of the sutures that makes this construct so successful.
Wayne Z. Burkhead Jr., MD: I am not sure the locking plate has changed my indications for ORIF of three- and four-part fractures. My confidence level, however, in treating young individuals with these devastating injuries without arthroplasty has increased because of modern locking plate technology.
The addition of features such as holes for suture placement, as well as a current design we are working on that allows a wire or heavy, nonabsorbable suture to be placed through the head or tuberosities to augment screw fixation proximally, promotes the creation of a stable surgical construct that will tolerate gentle passive range of motion in the early postoperative period.
Zuckerman: What are your indications for hemiarthroplasty?
Green: Four-part fractures and fracture dislocations in older patients are my primary indications for hemiarthroplasty. For younger patients I approach surgery with a goal to achieve anatomic ORIF. If this is not feasible, I convert to a hemiarthroplasty. It is difficult to select a specific age, but I lean more to arthroplasty for patients older than 60 years.
Egol: While I go into each case hoping to repair all proximal humerus fractures, I am prepared to perform a hemiarthroplasty.
Certainly there are situations in which the operative plan shifts quickly. I would reserve proximal humeral replacement for elderly patients with lower functional demand. In addition, fractures with severe varus head displacement or axillary dislocation are situations that would preclude me from considering internal fixation. Finally, head-splitting fractures in older individuals should be considered for hemiarthroplasty.
Wright: I use a fracture prosthesis hemiarthroplasty in older patients (physiologic) with true four-part fractures, three-part fracture dislocations and head-splitting fractures. In the very frail patient with three- or four-part fractures where I only absolutely want to do one operation, I will perform a fracture prosthesis. In younger patients, I will use a fracture prosthesis in head splitting fractures and neglected posterior dislocations with impression defects of greater than 50%.
Burkhead: My absolute indications for hemiarthroplasty for fracture include multipart fracture-dislocations where the humeral head is totally devoid of soft tissues. While there are some reports of success in treating these with ORIF, the risks of late collapse and avascular necrosis with subsequent head penetration by screws is higher than I would accept in my practice. In my hands, hemiarthroplasty for three- and four-part fractures in patients in their late 50s to their early-to-mid-80s has been a consistent operation. Having designed an implant with a medial hole for cerclage that had pads of porous coating in the areas of tuberosity fixation, and having used that implant from 1987 until 2003, my results in this age group with an anatomic reconstruction were very satisfactory. Advances in the designs that facilitate vertical and horizontal instability and now allow bone growth through the prosthesis leave me hopeful that these results will improve even further.
|
Image: Zuckerman JD |
My sense is that a well-done modern hemiarthroplasty that promotes tuberosity union can basically be looked upon as an operation that will last for the rest of the patient’s life in regards to loosening. Pain from late glenoid wear has been rare when the criteria of anatomic version, head radius match and tuberosity union are obtained.
Zuckerman: What intraoperative factors would lead you to change your operative plan from ORIF to hemiarthroplasty?
Green: If I find that I cannot achieve an acceptable anatomic reduction or stable internal fixation of the tuberosities and the articular segment, I may switch from ORIF to hemiarthroplasty. A good example of such a case is a three-part greater tuberosity fracture with some surgical neck comminution in an older patient. I typically inform such patients that I will attempt ORIF, but I will still have hemiarthroplasty available as another option.
Egol: Intraoperative detection of a head-splitting fracture is one situation that may cause me to change my plan from ORIF to hemiarthroplasty. Inability to attain secure fixation of the head fragment to the shaft is another reason that would push me toward performing a proximal humeral replacement. This situation is more likely to be found in elderly patients with significant osteopenia. Often augmentation with either cancellous bone graft or calcium phosphate cement allows for improved screw fixation within the head and may prevent this complication.
Wright: If, in the process of reduction it becomes obvious that the patient has an anatomic neck fracture and no soft tissue attachments to the head, or if the humeral head — in the process of reduction — “falls on the floor” (ie, there are no soft tissue attachments), I may switch to a hemiarthroplasty.
Burkhead: Intraoperative factors that would lead me to change are failure to obtain or maintain reduction of any one of the major fragments in an atraumatic fashion. An adjunct to this question is, “When would you go beyond a hemiarthroplasty and do a reversed shoulder prosthesis for a fracture?” Rarely the elderly patient with a four-part fracture has pre-existing cuff disease or tears. In these cases, I would actually perform a reversed prosthesis as the primary procedure. Most patients meeting these criteria would be in their 80’s.
Zuckerman: From a technical standpoint, what is the most critical part of performing a hemiarthroplasty?
Green: Greater tuberosity reduction and internal fixation are the most critical aspects of performing hemiarthroplasty. Greater tuberosity comminution is especially problematic. If the greater tuberosity is very fragmented, the fixation will not be as strong and the fragments are probably less likely to heal. Failure of tuberosity fixation, over-reduction of the greater tuberosity, and resorption of the greater tuberosity all lead to rotator cuff dysfunction and a worse outcome.
Egol: Restoration of the proper bone and muscle length/tension relationship is critical. Within the procedure there are several technical pitfalls that must be identified and addressed to prevent this complication.
Establishing proper humeral head height is critical to assure deltoid function. Following this, tuberosity repair to the shaft in a near-anatomic position will allow for normal rotator cuff function as well as minimize the risk of impingement.
Wright: The biggest challenge when using a hemiarthroplasty to treat a proximal humerus fracture is getting the tuberosities to heal where they belong. The surgeon can increase the probability of tuberosity union by using a prosthesis designed specifically for fracture treatment. This prosthesis will be small-bodied, preferably with a window to allow for bone grafting between the tuberosities.
The prosthesis will have multiple suture options and will have asymmetrical beds to allow a large bed for the greater tuberosity and a smaller one for the lesser. A surgeon using a true fracture prosthesis with good suture technique and bone grafting will increase the chance for success.
The other intraoperative challenge is to determine the best version of the prosthesis and head height. Version is typically placed at about 30° using the forearm as a guide, but we need to recognize that this is the average version, not necessarily the best version for every patient.
Another option is to use the distal bicipital groove, which one study showed to be more consistent than the proximal groove, and it is usually preserved in most proximal humerus fractures. However, another study has questioned the consistency of this landmark.
|
Head height can be determined using a number of methods, including looking at the original X-ray and seeing if the fracture comes out medially at the anatomic neck. If so, the inferior edge of the prosthetic head can be placed at the level of the fracture, restoring the anatomy.
Another method is to see if the tuberosities will fit neatly under the prosthesis and lie adjacent to the shaft.
The pull-down test is a simple test in which the trial prosthesis and head are placed and the arm is pulled down inferiorly, at which point the top of the head should be level with the top of the glenoid.
With the finger test, the surgeon pulls the arm inferiorly — with a trial prosthesis in place — and he should be able to easily place a finger between the top of the head and the acromion. If the finger fits too tightly, the prosthesis is too high; if it is very loose, the prosthesis is too low. While there are multiple methods of suturing tuberosities, we find that we can get excellent fixation by placing two horizontal sutures around each tuberosity, through the bone tendon junction and through the lateral fin. We follow this with rotator interval closure and placement of a vertical suture on the shaft of each tuberosity, and again through the tendon junction, followed by a cerclage suture.
Finally, it is also critical to keep cement away from the top of the shaft near where the tuberosities need to heal.
Burkhead: From a technical standpoint, simply stated humeral stem positioning is the most critical step. Anatomic version and stem height allows one to anatomically reproduce the head size and radius, maintain proper tuberosity height and promotes anatomic tuberosity reconstruction in a tensionless stable milieu. To perform this critical step properly one must do preoperative planning, intraoperative measurements and to a certain extent, have the experienced eye that allows one to visualize the Gothic Arch, the restoration of which is the goal of the procedure.
Green: Based upon my experience with ORIF and hemiarthroplasty, I prefer ORIF if I can achieve acceptable reduction and stable fixation. In my hands, if I can achieve this, the results have been more predictable and long lasting than hemiarthroplasty. But that being said, I usually do a hemiarthroplasty for a true four-part fracture or fracture dislocation in an older patient. Most importantly, don’t forget that valgus, impacted fractures should be treated with ORIF.