Chapters Transcript Proximal Humerus Fractures: Advances in Care Over the Last 15 years Course: 47th Annual Howard Rosen Memorial Tri-State Symposium That's good. Dislocation, uh, with the rest, uh, acute or chronic, both uh carry a risk of ABN and maybe, uh, and uh maybe uh a reason to choose orthopplasty over other treatment options. Sometimes the patient may have a displaced fracture that maybe I'm unable to internal fixation, but just the timing of presentation may be too far out that you may consider uh a replacement in that situation. Now before I delve into what indications are there for my practice, I just want to talk a little bit about rotator cuff, which is a very important structure in the shoulder, as we all know. Rotator cuff provides shoulder stability and dynamic fulcrum by concavity compression, allowing us to have a great range of motion with a stable shoulder. I look at a proximal humerus fracture with tuberosity displacement as a potential rotator cuff deficient shoulder. Which means to me that concavity compression is going to be lost or not optimal, and this is going to be an unopposed superior deforming force of the deltoid and what that means is that it can result in a mild situation as a rotator cuff dysfunction where a patient may not have the power to raise the arm above shoulder level or in extreme cases pseudo paralysis of anterior superior escape, both of which can actually result in the failure of an internal fixation. Greater tuberosity and the poster superior rotator cuff is actually protective of an internal fixation when patients starts doing the physical therapy at around 4 to 6 weeks, and both these conditions, you know, they can result in poor outcome even after non-operative repair. So what's the rationale for use of reverse in a proximal humerus fracture? In the last slide, as I alluded, I look at a displaced proximate humerus fracture with tuberosity displacement as a cuff deficient shoulder. Now reverse is a non-anaatomic constrained shoulder replacement. The diverse articulation actually converts the superior deforming force of deltoid into a compressedile force across the articulation. The center rotation moves from the humor head onto the face of the glenoid that provides stability to sheer forces on the base plate. Distalization of the center of rotation allows lengthening and improved tension of the deltoid, which becomes more efficient in bringing about compression and elevation in the forward plane. With that information, if we compare a reverse from a functional aspect to a hemming, which is another option, arthroplasty option in proximal humerus fractures, we don't have any issues with condor wear on the glimmer side because we are replacing both sides, so that's an advantage. It works in a cuff deficient shoulder compared to hemi, which is an anatomic orthroplasty. That means it requires a good functioning tuberosity healing in order to function. And reverse is a non anatomic construct that means restoring head height. Tubberosity reduction in an anatomic fashion are less critical compared to a hemi orthoplasty. It has more modular options. You can bring about a lot of soft tissue tensioning and stability with the reverse, whereas in a hemi orthoplasty you're limited with at the most a head size and a head height, and that sometimes can be an issue, especially if you are treating a delayed fracture. Now if you compare reverse from a mechanical or functional standpoint compared to internal fixation, again there's no risk of AVN, which does not necessarily mean it's gonna result in a poor outcome but definitely an advantage for the reverse. Again, just like hemming doesn't rely on tuberosity healing for forward elevation, may rely on tuberosity healing for other things, but not necessarily for forward elevation. However, not everything with reverse is gonna be good. There are complications with reverse that you need to know, like Doctor Twani alluded to that sometimes a non-operative treatment with the patient having a shoulder level function. will feel that, hey, I should have been given this option if they end up with one of these complications. It's a constrained prosthetic joint. Like Doctor Yanni mentioned that expectations have to be set, a patient with a proximal humerus fracture has memory only of a normal shoulder. They just know that they had normal range of motion. They got a fracture. The expectation is if the doctor says I'm gonna be that they're gonna fix my fracture, I should get that range of motion, but reverse. It's a constrained joint you can't have a normal range of motion, especially internal rotation behind the back. It's a big setback for a patient and one of the very common reason for an unhappy patient. You can fix the tuberosities, but they still can resorb, they still can have non-union. You may still have forward elevation, but these patients may have an internal rotation lag sign or an external rotation lag sign, and they can't really have uh a food with a spoon. They may have to rely on finger food, osteoporotic bone, you can have stem loosening at the cement bone interface because you are putting in a stem with cement and there isn't much canllus bone for the cement to bond. Periprosthetic fractures and other complications are reverse which may not be unique to proximal humerus fracture but can again result in a bad outcome. So let's talk about the indications are worse in my practice, and these indications pertain to patients who are more than 60, 65. We all agree in a younger patient, the bone quality is good. The intent is to fix them. They'll have a better outcome, better range of motion, and they get to preserve their own joint. So for reverse in my practice, a displaced 3 and 4 part proximal humerus fracture, that's a very broad indication. And this indication we'll go multiple other things that Doctor Tajwani listed, you know, what, what, what are the patient factors, what is the level of uh tuberosity comminution, what is uh the extent of impaction of the humeral head with the amount of can bone left in the humeral head. A displaced head split, not just a simple head split on a CAT scan, but a displaced head split fracture in combination with a 34 part fracture is an indication for reverse, and by indication doesn't mean that I'm treating all these patients with reverse. Again, a discussion is gonna happen, telling them about the NAA versus the reverse or worse as an internal fixation if it's an option, for example, in a displaced 3 or a 4 part uh fracture. And then the third indication is a proximal humerus fracture dislocation in an elderly where my my inclination would be to offer reverse. Then there are salvage indications in which reverse is really a good option, a failed hemiarthroplasty for a fracture indication, a failed internal fixation, or a fracture sequela like a malunited proxim humerus fracture or non-union fracture. Let's go over some of the cases. This is an acute three-part fractures, 73 year old female. You know, we can still be divided on this internal fixation versus the reverse based on the CAT scan degree of uh tuberosity, combination and impaction of the humer head. I choose a reverse where my goal is to have tuberosity reconstruction. Toberosity healing Make sure that the center rotation for the glenoid is distalized. There's a good inferior tilt, and this patient will have a good functional forward elevation and external rotation. A lock fracture dislocation 72 year old female, 3 weeks out, as Doctor Tajwan said, one of the indications where you don't debate, you just have to have the skills to do an operation that offers them good range of motion. Now this is a subset of patients. Even with the reverse, their outcomes are not gonna be similar to a reverse for a 3 or 4 part fracture which does not have dislocation. Most of the time these patients will have a lot of soft tissue damage. They're gonna have a lot of, uh, not HO but calcification along the capsule. They'll have a tight shoulder, so those expectations have to be factored in with the patient prior to operating. A head split, but as I said, and displaced fractures, 79 year old female, you know, elected for reverse again, the key is to get tuberosity reduction cemented stem here, distalized center rotation, inferior inclination of the glenoid, and this patient will heal the tuberosities and go on to have an appropriate outcome that is reasonable for a reverse. Fraction nonunion 78 male ophthalmologists, 1 year out, non-operative treatment has proximal migration of the hummo head. Non-union of the tuberosities 30 degrees of forward elevation. Poor outcome for reverse again trying to get the tuberosities reduced again, you know, having a distalized central rotation and fair tilt on the glenosphere have a construct that favors forward elevation tuberosities will allow you to have good external rotation and rotational control of the arm in space. Salvage indications, 79 year old female six week status post to RIF. Again, a good indication for reverse, same thing, get the tuberosities down at the level, get your, uh, glinosphere, uh, with an inferior tilt distalized center rotation. All those things are good principles to have when you're doing the reverse. Delayed presentation 72 male, 8 weeks out, status post fall. Doctor Tajwani elected to do this patient no up. I was running short of RVUs did the reverse and uh again, even in these cases you. Get the tuberosities reduced and follow the same principles. I know this talk is not a hemi talk, but again this is a hemi we saw on the trends. It's almost down to being rarely done, but this is a patient, 40 year old male, 5 weeks, proximal humerus fracture. Doctor Tajwani's well power view which he loves, posterior lock dislocation. I elected to do a hemi Hemi in my. Mind is 2 or 3 times more difficult operation than a reverse. You got to get the tuberosities if not perfectly close to perfectly reduced because that's the single most important factor that is gonna determine your stability of the hemi once the tuberosities have healed. Granted, there are other issues down the road in terms of condo wear and everything, but again, time T 0, you gotta get those tuberosities perfectly reduced and you don't have much modularity to get the head height or to get the the soft tissue tensioning in these patients. So what are the tips and tricks for a reverse when I'm doing for proximate humerus fracture as I alluded, tuberosity reconstruction is very critical for me. I secure the tuberosity with sutures, 3 sets of sutures for greater tuberosity, 2 for the lesser. Simple sutures tend to cut in old osteoporotic tuberosity, so I do a mattress loop suture, pass the sutures around the stem prior to reduction, otherwise it'll be a nightmare. And most important, don't overreduce the tuberosis. Everybody wants to close the book. In my mind, if I am tying the greater tuberosity, I am going to internally rotate the humor so that I don't overreduce the greater tuberosity when the time comes for lesser, I'm gonna externally rotate. So that I can't, I don't, uh, over tighten the lesser turosi. Now, a lot depends upon how you're putting stem. If your stem is in 40 degrees of retroversion, yeah, you don't need to bring, even if you bring the tuberosity to the mid the sagittal section of the uh stem, it'll be fine. But if your tuberoses and if you have fixed the stem in let's say 0 or 10 degrees of uh retroversion, and you try to bring the tuberoses to the mid-sagittal plane, you're gonna be over reducing the tuberosities. Another point, avoid overstuffing with glenosphere, which means depending upon the system you use, try not to lateralize because the rotator cuff is fixed length and you're gonna be tightening the tuberosis too much and having a stiff shoulder. Other important thing, avoid undersizing of the cemented stem. If you undersize the stem too much, the stem tends to, and if you're using a fractured stem, they tend to go into virus, and you're gonna have an eccentric eccentric cement mantle in the stem, and that can lead to an aseptic loosening pretty quick. Cement restrictor necessary but a devil. I, I can't tell you how many times I've heard a cement restrictor racing a stem distally, and you get one size that fits none. So you gotta make sure you cut the lanes, you look at the last reamer that you reamed the canal with, and just put the uh cement restrictor at the tip of that reamer and make sure it's not oversized. And if you don't have a proper one, just take the humor head. Pour out a plug which has cartilage and humorhead cartilage on it. The pod will be stiff. You can flip it and you can impact it. just ship it to the size. If you have a 10 reamer, just take the reamer and just uh size your own cement restrictor. So what's the evidence for reverse compared to other treatment options? There are a fair number of level 3 and 4 studies, some level 1 studies comparing reverse to an internal fixation and reverse to a hemi orthoplasty. And the evidence-based, uh, recommendations are based on a fair level evidence and as Doctor Tajwani mentioned on paper with evidence-based medicine reverse in a patient more than 65 does not offer any additional advantage. Uh, in a 3 or 4 part fracture. In absence of fracture dislocation or a displaced head split. Reverse is preferred over internal fixation for a 3 or 4 part fracture, but the evidence is inconclusive. Reverse has better outcomes, less complication compared to hemiarthroplasty, and a 3 or 4 part fracture in a patient above the age of 65, and there's a fair level of evidence for it. So one of the limitations when you're assessing this clinical evidence is that the hardcore indications that I listed or that we talked about in the previous talk as well for reverse are usually missing in these studies. Majority of these studies are not gonna have fracture dislocation. They're not gonna have displaced head splits, and they won't have delayed fracture fixation, which is basically a hard core indication for reverse if you're gonna offer a surgical treatment. So that should be kept in mind when you're looking at those evidence-based guidelines. In the end, uh, take home points, reverse is increasingly being used for surgical treatment of fracture dislocation and complex fracture patterns in patients over the age of 65. It provides early pain relief of very predictable forward elevation above the shoulder level. Now, Doctor Tajwani showed some of the patients who had like shoulder level function, but you know, predictability, if you're doing 100 patients, if you want predictability, I think reverse will give you more predictability in those complex situations. For me, indication and acute fracture is a displaced 34 part fracture. Well, I'll use it as a consideration. When all other criteria for tuberosity, comminution for head inaction, and other patient related fractures are met, a displaced head split fracture or a neglected presentation of an acute fracture, as a salvage indication, it's pretty straightforward, a failed surgical repair or an option for a symptomatic non-union or malunion of the fracture. As we do more and more of these fractures, be it non-operative, be it internal fixation or reverse, our understanding of the indications and impact of timing or reverse will continue to evolve, and I think we'll have much more clear idea of where to use and where not. I'm gonna end by saying the more I know about this fracture, the less I know. And uh it's just one of the very hard fractures uh to treat. I think surgically doing an operation is not hard. Just knowing what to do when is a complex uh affair which involves both the patient, the literature, your skill level and comfort doing all treatment options. Thank you very much. Published May 17, 2024 Created by Related Presenters Nirmal Tejwani, MD View full profile
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