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ORIF/Perc pinning good option in elderly patients
Ensuring that you have an anatomic reduction and a back-up plan are keys to success.
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Hemiarthroplasty
Hemiarthroplasty is probably the classic approach to four-part fractures, but this is not an easy procedure. The problem is getting the tuberosities to heal and to heal in the correct position. Furthermore, proper stem height and version are critical. Issues with malposition and overstuffing can result in problematic stiffness and failure of the tuberosity healing.
With tuberosity nonunion, rotator cuff function is absent and you can get anterior/superior escape where the humeral head component penetrates through the coracoacromial arch and to the patient this manifests as inability to lift their arm.
How real is this problem? Boileau et al in 2002 reported on 66 patients who received a hemiarthroplasty for an acute fracture. They noted that 28 of 66 (30%) were unsatisfied. An important difference to recognize with this population, compared to a population undergoing arthroplasty surgery for arthritis, is that they aren’t people who have been living with pain for extended periods. These are patients who right before the accident probably had a good shoulder. Any pain, weakness, and decreased motion following their acute injury is unsatisfactory to them.
Boileau recognized that the tuberosities are either malpositioned or detached in up to 50% of patients and this problem occurs in the hands of experienced shoulder specialists. The authors surmise that component malposition or tuberosity malposition is responsible for the high failure rate.
ORIF/Perc pinning
The classic indications for ORIF include two- and three-part displaced fractures, as well as the valgus impacted, four-part fracture.
The argument for using percutaneous pinning and ORIF for the four-part fractures is hemiarthroplasty isn’t doing so well. Other advantages to using ORIF/perc pinning are the availability to do them in young patients and recognizing that certain four-parts that have less risk for osteonecrosis if you achieve an anatomic reduction that heals. When we look at the fractures that have less of a risk for osteonecroses, we can put that into an algorithm of who we are going to treat with an ORIF or percutaneous pinning.
Technique
Pinning is my favorite technique for these fractures. I first ask can I pin it? If no, then can I plate it? And finally, I will consider doing a hemiarthroplasty. Pinning provides less soft tissue dissection, less disruption of the vascularity, less OR time, and less hospitalization.
There are, however, some criteria to meet before doing this operation. You need good bone quality to hold the pins and lack of medial metaphyseal comminution which compromises fracture stability. You also need patients who are going to comply with this operation — the pins are going to have to come out — and they have to be willing to be followed with X-rays to make sure that the pins are not migrating. They also have to be able to tolerate the discomfort. You need to tell them that they will feel pins underneath their skin.
I use 2.5 or 2.8 mm diameter pins that are terminally threaded. I also like to use 4-mm cannulated screws of various sizes and always have back up equipment in case I need to convert to plating or to a hemiarthroplasty.
The surgery is not technically easy, there is a learning curve. The first challenge is in getting the ability to see the fracture well with an imaging device.
The patient is in a beach chair position inclined at 30° with their thorax well over on the table, which has to be a table that will allow you to image through the shoulder. If you don’t have a table like that, use a bean bag to get them as far off the table as you can to get a look at the shoulder.
I bring a C-arm in from the head of the table and it is good if you have a C-arm tech who can get the images that you want because every time you go from the orthogonal view of an AP to an axillary it takes some time.
I use closed reduction maneuvers and hooks percutaneously to reduce the head to the shaft first, and sometimes impact it gently to get some stability. I place the lateral pins first, making sure I am below the axillary nerve and above the radial nerve. I go above the deltoid insertion thereby avoiding the radial nerve and also begin distal to the axillary nerve. I use a drill guide to protect the soft tissues so they don’t get wrapped as you are placing the pins.
I make a small incision along the anterior aspect of the acromion. Put in the hook to get the greater tuberosity anterior and inferior and manipulate the humerus for the reduction. For the greater tuberosity, you can externally rotate the humerus to assist the reduction and use the hook to get the tuberosity lateral. Once in position, you have fixation choices — you can put pins in, but they are not well tolerated compared to the inferior pins because they bang against the acromion. I like to use screws, there is no need for removal and they are tolerated better.
Postoperative protocol
Postoperative management must include weekly X-rays to check for pin migration. One of the tenants of fracture fixation is achieving stability that will allow the patient to move his or her shoulder so they don’t get stiff. Although, stiffness has not been as much of a problem as I originally thought with percutaneous pinning.
For rehabilitation, I immediately start them on pendulum exercises. During weeks 2 to 4 patients perform active assisted external rotation. At weeks 4 to 6, after the greater tuberosity pins are out, we begin passive forward elevation. After week 6 when all pins are removed we begin full active and passive range of motion.
In the literature, the reported results of pinning are shown to be pretty good, Resch et al in 1997 published results showing 88% good to excellent. Keener et al in 2007 looked at 27 patients with a minimum 1-year follow-up who were 60 years old with valgus-impacted, four-part fractures. All healed with good results with four malunions and four who later developed osteoarthritis.
Advantages
The advantages of percutaneous pinning are less soft tissue trauma, less disruption of vascularity, minimized blood loss, less OR time, better cosmesis, and decreased hospitalization.
The downsides: it is technically demanding, you’ll need fluoroscopy, there is a potential risk for neurovascular injury, pin removal and you do need a compliant patient.
For me, reduction and fixation for a four-part fracture should be considered if the patient is young, if it is a valgus impacted fracture in an older patient, and if it has a medial hinge which means it is stable and helps to avoid the risk of osteonecrosis.
For more information:
- Christopher S. Ahmad, MD, associate professor of orthopedic surgery, Columbia University, Center for Shoulder, Elbow and Sports Medicine, can be reached at 622 W. 168th St., New York, NY 10032; 212-305-5561; e-mail: csa4@columbia.edu. He has received grant research support from Arthrex Inc.
References:
- Ahmad CS. Controversies in shoulder and elbow arthroplasty. 72 year-old female with a 4-point proximal humerus fracture: ORIF/Perc pinning makes sense. Presented at Orthopedics Today Hawaii 2008. Jan. 13-16, 2008. Lahaina, Maui, Hawaii.
- Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11(5):401-412.
- Keener JD, Parsons BO, Flatow EL, et al. Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2007;16(3):330-338.
- Resch H, Povacz P, Frohlich R, Wambacher M: Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg (Br). 1997;79:295-300.