Treatment of Proximal Humeral Fractures with a Prosthesis Carl J. Basamania, MD, FACS The PolyClinic and Swedish Orthopaedic Institute Seattle, Washington Proximal Humerus Fractures • Common injuries: 5-7% all fractures (80,000/yr) • Humerus is the second most frequently fractured long bone of the upper extremity • 45% of humerus fractures • Female:Male - 2:1 • Increased incidence in elderly population • Osteoporosis – related • 80-85% minimally displaced/stable Introduction Proximal humerus fractures are the 3rd most common fractures in elderly patients As longevity increases the number of fractures is expected to grow substantially The Number and Incidence (per 100,000 individuals) of hospital treated osteoporotic fractures of the proximal humerus in patients 60 years and older in Finland from 1970 to 2002 Treatment of Proximal Humerus Fractures • General Rules: – “However you decide to treat a proximal humerus fracture, the most important rule is that you have to be able to move the patient right away…if you don’t, you’ll have pretty x-rays and no function.” » Charles A. Rockwood, Jr – Always err on trying ORIF rather than arthroplasty in younger patients – Good equipment will not make up for poor surgical technique Scarring – The Single Most Common Complication • Soft tissue damage – Increases with surgery • • • • Soft tissue swelling Bleeding Pain Immobilization Treatment • Considerations – – – – – – – – – Patient’s health/comorbidities Musculoskeletal comorbidities Bone quality—osteoporosis Degree of displacement Physiologic age Soft tissue Arm dominance Compliance Expectations/functional needs Fractures to Consider Hemiarthroplasty • Young/middle age – Nonreconstructable articular surface (severe head split) or extruded anatomic neck • Elderly – Most 4 parts – Some severe 3 parts – Most 3-, 4-part fracture dislocations – Most head splits Four-Part Valgus-Impacted Fracture • Head angulated and impacted • Not a true 4-part • ORIF + bone graft Surgical Principles • • • • • Maintain deltoid integrity Restore anatomy Restore humeral length Restore humeral version Maintain stable fixation of: – Tuberosities to each other – Tuberosities to shaft Challenges Unique to Fractures • Selecting proper prosthesis height • Proper humeral component version • Achieving anatomic and secure tuberosity fixation Advantages of Prosthetic Replacement • Secure fixation • Predictable pain relief • Revision of failed osteosynthesis is difficult Disadvantages of Prosthetic Replacement • • • • Larger incisions Time/blood loss Expense Complications serious/difficult Global Fx • Available Porous and Non Porous coated • Unique positioning jig Global Fx Prosthesis Advantages • • • • • • Thin body Markings Anterior fin Medial fin hole Reduced lateral fin Taper/Flute stem Surgical Approach • Beach Chair SURGICAL APPROACH • Beach Chair • Antibiotics • Preoperative scrub SURGICAL APPROACH • Deltopectoral Interval SURGICAL APPROACH • Deltopectoral Interval • Conjoined Tendon SURGICAL APPROACH • Deltopectoral Interval • Conjoined Tendon • Nerve Identification musculocutaneous SURGICAL APPROACH • Deltopectoral Interval • Conjoined Tendon • Nerve Identification musculocutaneous axillary Identify Biceps Identify Fracture Lines Measure Head Surgical Technique • Tuberosities tagged • Humeral head removed Surgical Technique • Ream Humeral Shaft • Establish Humeral Height Important Anatomic Relationships • The average neck-shaft angle is 40 to 45 degrees with a range of 30 to 55 degrees • Vertical distance between highest point of humeral articular surface and highest point of the greater tuberosity (head to greater tuberosity height) is ~8 mm with relatively small range of interspecimen variability Correct Head Height • The distance from the upper margin of the pectoralis major insertion to restore the anatomy should be 17.55% of the total humeral length. • Anatomy can be restored by placing the prosthesis 5.6 cm above the upper insertion of the pectoralis major – J Shoulder Elbow Surg 2008;17:947-950 Correct Head Height Murachovsky, et al. J Shoulder Elbow Surg, 15, 6, 2006 Surgical Technique • Ream Humeral Shaft • Establish Humeral Height • Establish Humeral Rotation Surgical Technique Surgical Technique • Cement Final Components • Tuberosity repair Tuberosity Repair to Anterior Fin Tuberosity Repair to Lateral Fin The “around the world” stitch • Mark A. Frankle, JSES, 2004 What contributes to better outcome? • Factors contributing to a favorable result include: – younger age, – male sex, – fracture type (i.e., three-part versus four part), – adequate rotator cuff repair or tuberosity reconstruction, – use of cement – sufficient postoperative rehabilitation compliance Prosthetic Replacement Outcome • 16 studies dealing with 810 hemiarthroplasties in 808 patients • Mean age of 67.7 years (22 to 91) • Mean follow-up of 3.7 years • Mean FF 105.7° (10° to 180°) and mean abduction 92.4° (15° to 170°) • Mean Constant score 56.63 (11 to 98) Prosthetic Replacement Outcome • Complications related to the fixation and healing of the tuberosities in 86 of 771 cases (11.15%) • Heterotopic ossification 8.8% and proximal migration of the humeral head 6.8% • Incidence of superficial and deep infection was 1.55% and 0.64% – Kontakis, et al. JBJS Br, 90-B: 1407 – 1413, 2008 Predictors of poor outcome • • • • Women over 75 years old had poorer results Humeral retroversion > 40 degrees Prosthesis >10mm above tuberosities Greater tuberosity >5mm above humeral head • Worst association was a prosthesis that was too high and too retroverted with a low greater tuberosity: the “unhappy triad” P. Boileau, et al, JSES, 2002 Poor Results • Malposition of either the tuberosities or head height can result in poor outcome – Boileau, et al, JSES, 2002 Disappearing tuberosities Disappearing Tuberosities Reverse TSA for Fractures • Average postop FF 97 degrees • In 36 shoulders in which the tuberosities had been fixed, secondary displacement occurred in 19 (53%), leading to malunion in five (13.8%) and nonunion in 14 (38.8%) • NOT APPROVED BY THE FDA FOR FRACTURES! Bufquin, et al, JBJS(B), 89-B, 4, 2007 Conclusions • Proximal humerus fractures represent the “last frontier” of fracture management • Very common • Typically complicated by osteoporosis • Fixation technique should be strong enough to allow early motion • Need to control scarring Thank you! Questions?? Complications • • • • • • Wound infection Nerve injury Instability Tuberosity nonunion/malunion Scarring Cuff Dysfunction