66-year-old woman with periprosthetic distal humerus fracture with minimal bone stock
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A 66-year-old woman with past medical history of chronic obstructive pulmonary disease, anxiety and osteoporosis presented to the ED after a ground level fall at home resulting in left elbow pain and deformity.
She had a history of left proximal humerus fracture treated with open reduction and internal fixation (ORIF) in 2015. This was complicated by nonunion, for which she underwent a revision surgery which was complicated by hardware failure with plate breakage. She then underwent a left reverse total shoulder arthroplasty with a long stem in 2021. Radiographs on this presentation demonstrated a periprosthetic intra-articular supracondylar intercondylar distal humerus fracture (Figure 1). On exam, she had no open wounds, ecchymosis throughout her left arm and was neurovascularly intact distally in the left upper extremity. She also was found to have a lateral compression type 1 pelvic ring injury.
What are the best next steps in management of this patient?
See answer below.
Sources: Ryan Anthony, MD; Nathan Callender, MD; Pooja Prabhakar, MD; and Erika Roddy, MD
Open reduction and internal fixation
There were several challenges in managing this patient’s fracture with a goal of a stable elbow to allow for motion and function. First, given that she fractured at the tip of her stem, there is limited bone stock for fixation proximal to the fracture as the long stem in her reverse TSA took up most of her humeral canal. In addition, the stem impacted into the lateral condyle and capitellum, resulting in minimal bone stock distally on the lateral side. She also had osteopenia and poor bone quality.
Nonoperative management was an option and is known as “bag of bones” treatment for distal humerus fractures in low-demand older patients with osteoporotic bone. However, this would invariably result in poor elbow function. There were then two main surgical options: ORIF around the current implants or an attempted explant of the long reverse TSA implant with conversion to a shorter stem reverse TSA implant and concomitant total elbow arthroplasty for her acute fracture while spanning the intervening area with a plate. However, given her poor bone quality, it was thought that any attempt at reverse TSA explantation would lead to significant bone loss. ORIF around her current implants remained challenging given minimal bone stock around the reverse TSA proximally and the possibility for nonunion distally given the minimal remaining bone stock in the distal lateral column. Despite this, her medial column may be able to heal, which would give her a stable hinge for elbow function and motion. We discussed the nature of the injury, the difficulties of treatment and risks and benefits of surgery with the patient, and she wished to proceed with ORIF around the current implant.
Surgical procedure
The patient was positioned lateral. Following administration of general anesthesia, her left upper extremity was prepped and draped in the usual sterile fashion.
A 20-cm longitudinal midline posterior incision was made, and full thickness flaps were raised medially and laterally. Medially, the interval between the triceps and the medial intermuscular septum was created and the ulnar nerve was identified, which was carefully dissected and freed so it could be retracted medially in a tension-free manner. The cubital tunnel was released from Osborne’s fascia to flexor carpi ulnaris fascia until the first motor branch of the ulnar nerve to the flexor carpi ulnaris was visualized. The triceps was then elevated off the bone to expose the fracture medially.
Attention was turned to the lateral side and the lateral paratricipital approach was developed, elevating the triceps off the lateral intermuscular septum and exposing the fracture laterally. The fracture was thoroughly debrided with scalpel, dental pick and irrigation. The reverse TSA stem in the proximal segment was visualized and was well-fixed. An attempt was made to reduce the medial column to the shaft; however, the attempt was unsuccessful, and the decision was made to proceed with an olecranon osteotomy. The ulna was exposed in the interval between the extensor carpi ulnaris and flexor carpi ulnaris, and an olecranon plate (DePuy Synthes) was positioned on the ulna and wired into place. Screws were pre-drilled, the plate was removed and a chevron osteotomy was created at the bare spot.
The triceps and proximal ulnar fragment were retracted proximally, and the medial column was able to be reduced and held with a series of clamps. The lateral column was reduced to the medial side with K-wires as joy sticks and held using a series of K-wires across the articular surface. Visual inspection as well as fluoroscopic imaging confirmed an excellent reduction (Figure 2). It was challenging to maintain the lateral condyle reduction, as expected, given there was essentially no bone there, just a cartilage shell with 2 mm of subchondral bone underneath. A medial plate was positioned on the humerus and wired into place, and a short nonlocking screw was placed proximally to bring the plate down to bone. Several additional locking screws were placed proximally and several locking screws were placed distally. Cement was mixed and packed into the lateral condyle around the screws (Figure 3). Once it hardened, the elbow was flexed and, unfortunately, this resulted in the cement pulling out of the subchondral bone on the lateral side resulting in loss of fixation laterally. It also resulted in the lateral epicondyle pulling off the capitellum. Therefore, the distal screws were removed and switched to shorter screws only capturing the trochlear fragment. The cement was removed, and another bag of cement was mixed and packed into the lateral condyle.
Once the cement was hardened, the cement-bone interface was stressed and it appeared stable this time. Then the lateral column was reduced to the medial column, and this reduction was held with several 0.054” K-wires, as well as with a large clamp. The distal screws were then redrilled from the medial plate so that it drilled into the cement, with the short screws being replaced with long screws that captured the lateral condyle. A posterolateral variable angle distal humerus plate (DePuy Synthes) was positioned on the humerus and wired into place. Care was taken to ensure the radial nerve was protected given this was a long posterolateral plate. Multiple locking screws were placed proximally and two locking screws were placed distally to capture the lateral condyle. More than two screws distally in the posterolateral plate were not placed given this piece was captured already with several screws from the medial plate and to avoid the risk of fragmenting the cement with too many drill holes. Fluoroscopic imaging demonstrated a satisfactory reduction (Figure 4).
To repair the lateral ulnar collateral ligament to the lateral epicondyle, several high-strength braided sutures in locking Krakow fashion were placed into the lateral ulnar collateral ligament and tied down to the posterolateral plate with the elbow at 30° of flexion and slight valgus, as there was not enough bone in the lateral epicondyle to capture it successfully with screws. More cement was packed into the metaphyseal defect laterally. Then, the olecranon was fixed with two modified clamps to reduce the osteotomy and K-wires as provisional fixation. The plate chosen earlier was reintroduced and the screws that were drilled previously were fixed into place. An additional locking screw was placed proximally into the olecranon aiming up into the olecranon tip, and two additional screws were placed in the distal segment. Final fluoroscopic images including a view down the proximal radioulnar joint confirmed a satisfactory reduction and safe hardware placement. The wound was thoroughly irrigated and closed in layers. An incisional wound vacuum-assisted closure was placed. Plain radiographs were then taken demonstrating satisfactory coronal and sagittal plane alignment and articular reduction (Figure 5), and safe hardware fixation. A long-arm splint was placed, and the patient was recovered from anesthesia.
Follow-up
At 1 week postoperatively, the patient was transitioned from a long-arm splint into a neutral orthoplast splint and instructed to come out daily for passive motion at the elbow following a terrible triad rehabilitation protocol. This included supination and pronation when the elbow is flexed past 90°, and elbow flexion and extension with the forearm pronated. At 3 weeks postoperatively, her wounds were well healed.
Discussion
Periprosthetic distal humerus fractures are challenging fractures to treat and are becoming more frequent given the increasing numbers of shoulder arthroplasties and revision shoulder arthroplasties. Complication rates for reverse TSAs have been reported as being 3% to 68%, including infection, instability, loosening and periprosthetic fractures. Periprosthetic humerus fractures can occur intraoperatively or postoperatively, occurring 0.9% to 3.5% and 1% to 3%, respectively.
Long-stem implants, as demonstrated in this case, limit proximal fixation of distal humerus fractures. The alternatives to isolated fixation include fixation plus explantation of any long-stem implant with conversion to a short-stem implant, which allows more space for fixation proximally. In addition, a total elbow arthroplasty, distal humerus hemiarthroplasty or distal humerus megaprosthesis could be placed for distal fractures, and the bone between the implants can be plated. The major risk with this option is bone loss during extraction of the long-stem implant.
Key points
- There are limited options for fixation of periprosthetic distal humerus fractures around a long stem.
- ORIF or long-stem reverse TSA explantation with distal humeral arthroplasty implants are the two main options, although the limited bone stock requires careful screw placement, as well as potential need for bone cement.
- References:
- Caredda M, et al. J Orthop Surg Res. 2024;doi:10.1186/s13018-023-04465-2.
- Gebrelul A, et al. Annals of Joint. 2018;doi: 10.21037/aoj.2018.06.02.
- Kobayashi E, et al. OTA Int. 2023;doi: 10.1097/OI9.0000000000000244.
- Taylor J, et al. JSES Rev Rep Tech. 2021;doi: 10.1016/j.xrrt.2021.08.002.
- Trompeter A, et al. Strategies Trauma Limb Reconstr. 2013;doi: 10.1007/s11751-013-0155-x.
- For more information:
- Ryan Anthony, MD; Nathan Callender, MD; and Pooja Prabhakar, MD, can be reached at the department of orthopaedics and sports medicine at the University of Washington Medical Center. Erika Roddy, MD, can be reached at the department of orthopaedics and sports medicine at the Harborview Medical Center. Prabhakar’s email: prabhaka@uw.edu.
- Edited by Andrew Bi, MD, and Pooja Prabhakar, MD. Bi is a chief resident in the department of orthopedic surgery at NYU Langone. He will pursue a fellowship in sports medicine at Rush University Medical center following residency completion. Prabhakar is a chief resident in the department of orthopaedic surgery at the University of Washington. She will pursue a fellowship in foot and ankle surgery at Baylor University Medical Center following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
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