31st Annual Congress of Orthopaedic and Traumatology Association Macedonia-Thrace April, Thessaloniki-Greece
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1 31st Annual Congress of Orthopaedic and Traumatology Association Macedonia-Thrace April, Thessaloniki-Greece SHOULDER ARTHROPLASTY FOR POST-TRAUMATIC OSTEOARTHRITIS Dr. Iosif Gavriilidis-Orthopaedic Surgeon-Scientific Cooperator of 2nd Orthopaedic Department Aristotle University of Thessaloniki
2 SEQUELAE OF FRACTURES Difficult situation for shoulder reconstruction Distortion of proximal humeral anatomy Tuberosity-diaphysis continuity Need of a greater tuberosity ostetomy
3 SEQUELAE OF FRACTURES Complication of displaced proximal humeral fractures Complexity of bone loss Soft tissue abnormalities Arthroplasty is a valuable but unpredictable treatment Neer CS. Shoulder Reconstruction 1990 Cofield RH. Clin. Orthop. 1983
4 SEQUELAE OF FRACTURES Surgical technique is a callenging situation (Boileau P. JSES 2001) Arthroscopy with debridement Rotational osteotomy (Weber BG. JBJS Am 1984) Allograft to restore joint congruity (Richmond JC. Arthroscopy 2006) Bone transfer techniques (Gebhard F. Unfallchir. 1997)
5 SEQUELAE OF FRACTURES Shoulder arthroplasty good treatment option Satisfactory long-term pain relief Good function Boileau P.CORR 2006 Cofield RH. JSES 2002 Loew M. JBJS Br. 2010
6 SEQUELAE OF FRACTURES Severe displacement osteotomy and refixation Borderline cheating with small stem, short head and varus position Glenoid is rarely used when the injury< 6 mths but 76% TSA when > 6 mths Neer CS. Shoulder Reconstruction 1990
7 CLASSIFICATION
8 CLASSIFICATION Aequalis group (multicenter) 71 patients 65% Hemi, 35% TSA Better results of arthroplasty without osteotomy of greater tuberosity New classification of sequelae of fractures of the proximal humerus Boileau P. JSES 2001
9 Intracapsular, impacted Extracapsular, disimpacted Type I: Cephalic collapse or necrosis Type II: Locked or fracture dislocation Type III: Surgical neck non-unions Type IV: Severe tuberosity malunions
10 MECHANISM OF INJURY Compression injuries moderate sequelae Rotational or shearing injuries major sequelae
11 SEQUELAE OF FRACTURES
12 SEQUELAE OF FRACTURES Avoid osteotomy of greater tuberosity Only possible with modular prosthesis
13 SEQUELAE OF FRACTURES
14 AIM OF STUDY Evaluation of the influence of type of fracture according to Boileau on the clinical and radiological outcome Habermeyer P., Gavriilidis I. SECEC 2009 Madrid
15 MATERIAL AND METHOD arthroplasties for sequelae of proximal humeral head fractures 37 patients > 1 year follow-up (average 30 months) Age: 58 years (31-77years) 21 Hemi 16 TSA % CS
16 MATERIAL AND METHOD I: 54% III: 16% II: 8% IV: 20%
17 RESULTS Pre-Op Post-op CS overall Intracaps Extracaps
18 RESULTS TSA VS. HEMI Pre-Op Post-op CS overall TSA Hemi
19 RESULTS Pain Pre-OP Post-OP Intracaps Extracaps
20 RESULTS ADL Pre-OP Post-OP Intracaps Extracaps
21 RESULTS Strength Intracaps Extracaps Pre-OP Post-OP
22 RESULTS ROM Pre-OP Post-OP 5 0 Intracaps Extracaps
23 RESULTS Correlation of post-op Constant Score and Boileau fracture type r= (p=0.009) (Pearson correlation)
24 RESULTS RLL in one zone 1 mm in 4 cases (10.8%) in humeral component No RLL in glenoid component No loosening
25 Type I RESULTS
26 RESULTS Function 12 months post-op
27 Type II RESULTS
28 RESULTS Function 10 months post-op
29 Type IV RESULTS
30 RESULTS Function 12 mths post-op
31 COMPLICATIONS Antero-superior RC insufficiency (5x) Only in types III/IV (corr. r= 0.531) 1 infection, no fractures
32 DISCUSSION Author N FU CS Complications Boileau P JSES months I:62,II:61 III:36,IV:42 27% Cofield RH JSES 2002 Mansat M JSES 2004 Brunner U Orthopade years 61 (81%) 16% months 54 8% months 56 17% Habermeyer P SECEC months I:83%,II:66% III:62%, IV:51% 16%
33 DISCUSSION
34 DISCUSSION pts type I,II Age: 60 years Follow-up:minimum 2 years CS: 55.1
35 DISCUSSION Type of initial fracture Technical difficulties Complications Functional outcomes Completely different for intra- and extracapsular
36 DISCUSSION The greater tuberosity does not seem to tolerate this second fracture Greater tuberosity nonunion, migration and resorption is the reason for the poor results Abandon the idea of reconstructing normal anatomy of the proximal humerus at any cost Modular prosthesis for changing the inclination and offset of the prosthetic articular surface Boileau P. JSES 2001
37 DISCUSSION Soft tissue injury has a substantial impact on the clinical outcome Modular and adaptable prosthesis is of particular utility for type I,II Type III and IV inappropriate for nonconstrained prosthesis Tuberosity osteotomy degrades functional results because of difficulty with healing and impairment of cuff function
38 DISCUSSION
39 DISCUSSION
40 CONCLUSION Types I/II show best functional result Types III/IV show good pain relief, but no good functional result Look for glenoid problems Posttraumatic arthritis does not automatically mean HEMI, think of TSA Counseling of patients important for subjective expectations
41 CONCLUSION Technically demanding procedure Adequate exposure Proper correction of soft tissue abnormalities Preservation of the greater tuberosity or meticulous reattachment is of paramount importance
42
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