Shoulder Hemiarthroplasty for treating proximal humeral fractures
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1 Shoulder Hemiarthroplasty for treating proximal humeral fractures Aloplastyka połowicza w leczeniu złamań bliższego końca kości ramiennej Michał Łaszczyca, Damian Kusz Katedra i Klinika Ortopedii i Traumatologii Narządu Ruchu Śląskiego Uniwersytetu Medycznego w Katowicach Kierownik: prof. dr hab. med. Damian Kusz 1
2 Proximal humeral fractures Epidemiology Incidence - 5% of all fractures (third most common) - 80% of all humeral fractures - over 85% patients had low bone density - 80% of cases affects women - increases with age - 8% lifetime risk of fractures for women > 60yrs 2
3 Proximal humeral fractures Etiology More frequently - low energy injury (fall from a standing height, on the outstretched hand) - elderly patients, usually females > 60 yrs Less frequently - high energy trauma (sports injury / car accident) - younger patients, complex fracture patterns 3
4 Proximal humeral fractures Anatomy Segments GT head Fracture type anatomical neck AN surgical neck SN greater tuberosity GT LT lesser tuberosity LT fracture dislocation shaft head split 4
5 Proximal humeral fractures CT scans 3-D reconstructions 5
6 Proximal humeral fractures Classification: Neer with modifications - the most popular - number of fracture parts: head / greater tuberosity / lesser tuberosity / shaft - displacement = more than 10mm (GT >5mm) or 45 angulation, fracture-dislocation 1-part fracture (nondisplaced) 70-80% 2 -part fracture ~20% 3 -part fracture ~5% 4 -part fracture <5% Articular surface Head spliting Neer CS II: Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am 1970:52[6]:1079.) 6
7 Proximal humeral fractures Classification: Hertel Predictors of humeral head ischemia - disruption of medial hinge - length of dorsomedial metaphyseal spike attached to the head fragment R. Hertel, A. Hempfing, M. Stiehler, M. Leunig. JSES, Volume 13, 2004, Pages
8 Proximal humerus blood supply Vessels anterior humeral circumflex rotator cuff tendon vessels arcuate posterior humeral circumflex arcuate rotator cuff tendon vessels posterior humeral circumflex periosteal anterior humeral circumflex 8
9 Proximal humerus - Avascular necrosis Avascular necrosis of the humeral head - AVN Vascular disruption more likely with -soft tissue displacement and -higher energy fractures Factors related to humeral head ischemia + metaphyseal head fragment extension < 8 mm, + medial head disruption > 2 mm + fracture with dislocation + head-split components = all - 97 % predictive for head ischemia Fracture nonunion and tuberosity reabsorption - injury of the arcuate + extraosseous collateral circulation - anterior + posterior humeral circumflex vessels disruption 9
10 Proximal humeral frx - Treatment Treatment algorithm Decision : + patient factor + injury factor Khmelnitskaya et al. Evaluation and Management of Proximal Humerus Fractures. Advances in Orthopedics 2012:
11 Proximal humeral - Treatment Proximal humeral fractures - Treatment Non-operative treatment 75 85% are minimally displaced - successfully treated without surgery 15-20% are comminuted or displaced - require surgical intervention 11
12 Proximal humeral - Treatment Treatment Closed reduction and percutaneus fixation Open reduction and interlocking plates Complications - nonunion - displacement - osteonecrosis ( 20-50% ) - screw cut-out Proximal humeral nailing 12
13 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty 40% of operated fractures Indications: patient better than fixation in >70 y.o. better than reverse arthroplasty in young facture - 4 part fractures - 3 part with poor bone quality or risk of AVN - head split, destruction of articular surface - failed previous surgery - avascular head necrosis Contraindication - coracoacromial ligament deficiency - glenoid arthrosis - rotator cuff deficiency 13
14 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty timing The time from injury to surgery --acute <4 weeks much better outcomes --late/chronic >4 weeks - risk of capsular stiffness, rotator cuff insufficiency and AVN 14
15 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty anatomy Restore function and imitate natural anatomy Natural head - diameter ~ 46 mm (37mm - 55mm) - height ~ 8 mm superior to the greater tuberosity - 30 of retroversion (6.7 anteversion 47.5 retro), - inclination 130 to the shaft Prosthetic head size and positioning - diameter mm, similar to the removed head - top - 55mm over margin of pectoralis major tendon of retroversion 15
16 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty anatomy Tuberosity healing is the main condition for success Positioning - anatomic reduction - fixation with each other, with shaft and with stem - bone grafting - greater tuberosity 10mm below articular surface of head - GT malposition and malunion postero-superior displacement deltoid force 29 % 16
17 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty biomechanics Imitate natural biomechanics Kinematics 1. Flexion/Extension 2. Abduction/Adduction 3. Medial/Lateral Rotation 1. Rotation - spin (pure flexion/ext) 2. Rolling (Abduction/Adduction) 3. Sliding (MedRot/LatRot) 17
18 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty muscle function Apropriate tuberosities and cuff reconstruction provides stability and mobility of the prosthesis 18
19 Proximal humeral - hemiarthroplasty Shoulder hemiarthroplasty muscle function Superficial and deep muscles of the shoulder - balanced forces - axis, rotation center 19
20 Hemiarthroplasty Clinical decisions case #1 B.K. male 71 3part/nonunion 20
21 Hemiarthroplasty Clinical decisions cases case #2 K.I. female 74 4part/med. hinge 21
22 Hemiarthroplasty Clinical decisions case #3 P.K. female 70 AN+GT 22
23 Hemiarthroplasty Clinical decisions case #4 J.K. female 68 4part 23
24 Hemiarthroplasty Clinical decisions cases case #5 S.F. female 62 head split/disl. 24
25 Hemiarthroplasty problems Inappropriate implantation stem - too short inferior subluxation and instability - too high subacromial impigement and decreased ROM - excessive anteversion anterior instability - retroversion posterior instability head diameter - too large stiff joint - too small glenoid damage and instability 25
26 Hemiarthroplasty Outcomes Good result -treatment selection (fracture, age, time from injury) -prosthesis selection (status of the rotator cuff), -optimal implant positioning -optimal management of tuberosity fixation, -appropriate rehabilitation protocol 26
27 Hemiarthroplasty Complications Hemiarthroplasty complications -joint stiffness -rotator cuff dysfunction -superior migration of the prosthesis -instability -tuberosities nonunion, -glenoid arthrosis, -stem loosening -humeral periprosthetic fracture -infections 27
28 Hemiarthroplasty Complications Reverse Total Arthroplasty Fortunately, we have one more solution... 28
29 Hemiarthroplasty Thank You for Your Attention 29
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