Achieve stable fixation to initially start full range of motion (ROM) and to prevent secondary displacement in unstable fracture patterns and/or weak and osteoporotic bone.
Indications
(Secondarily) displaced proximal humerus fractures (PHF) with an unstable medial hinge and substantial bony deficiency, weak/osteoporotic bone, pre-existing psychiatric illnesses or patient incompliance to obey instructions.
Deltopectoral approach. Identification of the rotator cuff. Disimpaction and reduction of the fracture, preparation of the situs. Graft preparation. Allografting. Fracture closure. Plate attachment. Definitive plate fixation. Radiological documentation. Postoperative shoulder fixation (sling).
Postoperative management
Cryotherapy, anti-inflammatory medication on demand. Shoulder sling for comfort. Full active physical therapy as tolerated without pain. Postoperative radiographs (anteroposterior, outlet, and axial [as tolerated] views) and clinical follow-up after 6 weeks and 3, 6, and 12 months.
Results
Bony union and allograft incorporation in 9 of 10 noncompliant, high-risk patients (median age 63 years) after a mean follow-up of 28.5 months. The median Constant–Murley Score was 72.0 (range 45–86). Compared to the uninjured contralateral side, flexion was impaired by 13 %, abduction by 14 %, and external rotation by 15 %. Mean correction of the initial varus displacement was 38° (51° preoperatively to 13° postoperatively).
Hinweise
Editor
A.B. Imhoff, Munich
Illustrator
J. Kühn, Mannheim
Introduction
This technique may reinforce and augment internal plate fixation in displaced proximal humeral factures (PHF) with an unstable medial hinge, especially in weak and osteoporotic bone with substantial loss of the structural bony scaffold. Compared to conventional plate fixation methods, it may not only decisively increase bony stability and prevent secondary fracture displacement, but also allow for full initial range of motion (ROM) [1].
Surgical principles and objective
To augment surgical fixation and to achieve postoperative stability strong enough to initially start full ROM and to prevent secondary displacement in unstable fracture patterns and/or weak and osteoporotic bone.
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Advantages
Joint preserving method without artificial material
Increased stability after open reduction and internal plate fixation of PHF
Anatomic reduction in cases of substantial bone loss using a biological structural void filler
Strong structural bony congruency
No additional surgical approach, wound site, or donor morbidity
Average technical skills demanded
Initial full weightbearing and ROM
Potential prevention of secondary postoperative fracture displacement
Very low infection rates or graft-versus-host reactions [1, 3]
Solid bone stock for potential secondary prosthetic interventions
Disadvantages
Allogenic bony material
Potential risk of infection, transmission of diseases and graft-versus-host reaction
Minimal risk of nonunion
Minimally increased operation time
Limited accessibility to allografts
Increased costs if not derived by in-house bony banks
Indications
(Secondarily) displaced 2‑part proximal humerus fractures (PHF) with an unstable medial hinge and substantial bony deficiency
Cases of weak and osteoporotic bony structure
Increased risk for secondary displacement due to pre-existing psychiatric illnesses or patient incompliance to obey rules [2, 5]
Implant failure (screw perforation, loosening, breakage, or intolerance)
Nonunion
Bony dissolution over time
Disintegration and secondary displacement
Re-operation
Infection, thrombosis, embolism, vascular or nerve damage
Preoperative work up
Bilateral shoulder CT and 3D reconstruction to distinctively assess the grade of displacement and/or the size of the bony defect
Pre-order (in-house bank or third party) of an appropriately sized bony allograft (at least one half of a femoral head)
Femoral heads seem to be rather nonosteoporotic if derived from a replacement surgery of an arthritic hip
The allograft should be fresh frozen and test negatively for transmittal diseases, contamination, and infection, no antibiotic treatment or preserving processing to the graft prior to implantation
Thawing of the fresh frozen graft to room temperature at least 1 h prior to surgery
Shaving of the complete shoulder region, including axilla
Single shot intravenous antibiotic administration (bone consistently, at least 30 min prior to the skin cut, i. e., aminopenicillin) [4]
Instruments
Bone saw to decorticate the allograft
Luer-like instruments (Rangeur)
Anesthesia and positioning
General anesthesia
Interscalene block (beneficial and recommended, but not mandatory)
Supine position and mild angulation of the upper body (approximately 20°; Fig. 1)
Positioning on the edge of the table with the arm freely movable on an optional adjustable table (Fig. 2)
Regular prepping and wrapping
Fig. 1
Supine positioning of the patient with the upper body elevated by approximately 20° and the shoulder extending from the table’s edge, allowing the surgeon free manipulation
Fig. 2
Positioning of the optional mobile arm table (soft surface and edges), adjustable in height and freely movable
Surgical approach. Deltopectoral approach, 10–12 cm in length. The incision starts distally to the coracoid, continuing distally towards the ventral humerus, orienting just above the medial border of the deltoid muscle, lateral to the axilla. The subcutaneous fatty tissue is then cut to expose the deltopectoral fascia underneath
Fig. 4
Deep deltopectoral approach. Sharp or blunt skin retractors should be used to display the surgical situs. The cephalic vein is then identified underneath the fascia (white arrows), dividing the deltoid muscle laterally, and the pectoralis major muscle medially. Prepping to its medial site, the vein is held laterally, still attached to the deltoid muscle. White asterisk indicates the deltoid
Fig. 5
Fracture situs. Identifying the coracoid in the depth, careful blunt division of deltoid and pectoralis major muscles is performed from proximal to distal. Originating from the coracoid, the conjoint tendon may now be identified and retraced medially to display the fracture situs (a four-part fracture of the proximal humerus is shown in the drawing). Special care should be taken not to harm the axillary nerve
Fig. 6
Identification of the rotator cuff. Prior to the reduction of the fracture, the functional components of the rotator cuff have to be identified and looped. Anatomically, the long head of the biceps tendon (LHB) and its bicipital groove on the humerus divides the lesser tuberosity (anterior part of the rotator cuff, subscapularis tendon) from the greater tuberosity (lateroposterior part of the rotator cuff, supraspinatus (SSP) and infraspinatus tendons). Stay sutures at the tendon bone interface are placed to be able to gently manipulate the fragments. Usually, the fracture line between the tuberosities runs about 8–10 mm posterior to the bicipital groove. In cases of four-part fractures, or whenever sutures are crossing the sulcus, the LHB is identified and cut above the pectoralis major’s tendon and sutured to the tendon. Any intertuberosity fracture is followed to the SSP, which is split longitudinally to entry the joint. The proximal portion of the LHB is cut at its origin on the superior glenoid and removed. In case of any three-part fracture (greater tuberosity involved) without a fracture of the bicipital groove, the LHB is not treated at all
Fig. 7
Disimpaction and reduction of the fracture, preparation of the situs. All three functional components of the rotator cuff are looped to later easily close the cuff and secure it to the plate. Fracture displacement and impaction may now be reduced and the fracture is “opened”. Manipulating the elbow, mildly rotating and pulling the shaft component may help to properly reduce the fracture and to align the fracture components. Drawing of the partially “opened” fracture situs. The LHB is followed medially and cut at its origin using a scissors
Fig. 8
Preparation of the allograft. Any soft tissue or articular cartilage is dissected off the allograft using a saw. To allow for secure positioning within the distal shaft component and to serve as a scaffold with the largest possible surface for the head fragment at the same time, the graft is shaped like a “mushroom” or “Champaign plug”. a Fresh frozen partial femoral neck (left) and head (right) allografts. b Dissection of the allograft (off patient). c,d Pretreated allograft with all cartilage dissected
Fig. 9
Detailed graft preparation. In the ideal case of a femoral head allograft, the femoral neck may represent the mushroom’s stem, and the femoral head may represent the carrying surface component. Ideally, the dense subchondral zone of the femoral head is preserved to build the strong mushroom’s “hat”. The graft is oversized with approximately 30 mm in width and height. However, individual tailoring of the allograft is necessary. In order to allow easy removal, which will be necessary to exactly shape the graft for the individual defect’s size, No. 1 Vicryl is used to loop and secure the graft around its neck. a,b,c,d “Mushroom”-shaped allograft, approximately 30 mm in width and height. d Looped and secured using No. 1 Vicryl
Fig. 10
“Allografting”. The graft is then implanted into the fracture situs, with its stem (dashed line) facing the humeral shaft, and its roof filling the hollow humeral head. Using Luer forceps, the graft is adjusted. This step is crucial, since the allograft has to be removed several times to perfectly tailor it to the individual fracture and defect site without breaking it
Fig. 11
Fracture “closure”. Once the allograft fits macroscopically, the head and the tuberosities are reduced using No. 1 Vicryl wires. A 2.0 mm Kirschner wire is used to temporarily retain the reduction. SSP split is repaired
Fig. 12
Intraoperative fluoroscopy. Anteroposterior (a) and axial (b) fluoroscopic radiographs. White arrows indicate the allograft
Fig. 13
Plate attachment. Finally, an appropriately sized proximal humerus locking plate is attached directly lateral to the bicipital groove and temporarily fixed using a cortical screw in the gliding hole and two Kirschner wires. Using the fluoroscope, the plate is adjusted and positioned
Fig. 14
Definitive plate fixation. At least six locking head screws, including A and E levels (if at all possible to maximize the screws’ lever arm), and three bicortical shaft screws are inserted. Optionally, the functional components of the rotator cuff may be secured and knotted to the plate. Lateral (a) and anteroposterior (b) views. Allograft and humeral head highlighted translucently for better visualization
Fig. 15
Anteroposterior (a1, b1, c1) and lateral (a2, b2, c2) schematic drawings of the preoperative (a1,2), intraoperative (b1,2), and postoperative (c1,2) proximal humerus. Pink “mushroom” indicating the structural allograft and its positioning within the proximal humerus in b1,2, and c1,2
Fig. 16
Radiological documentation. Anteroposterior (a) and axial (b) fluoroscopic views are obtained to document the proper position of the allograft and the fracture reduction. After copious lavage and hemostasis, the skin is closed in layers (subcutaneously and the skin itself, additional closure of deep structures like muscles or fascias is not recommended). Adhesive dressing, shoulder sling until interscalene block is dissolved, and for comfort afterwards (see Fig. 15 for details). Anteroposterior (a) and axial (b) fluoroscopic radiographs, intra- (post-)operatively. White arrows indicate allograft
Fig. 17
Postoperative shoulder fixation. Shoulder sling for comfort
Months 3, 6, and 12: clinical FU, ap, ov, and ax radiographs
Errors, hazards, complications
Allograft cut too small: use of the cut parts as additional bony putty around the graft to achieve a press fitting construct prior to definitive fixation
Infection of the allograft: indication for surgery and explantation of the graft; implantation of a spacer, several surgical re-looks as needed, and priming for the definitive procedure (i. e., implantation of an antibiotic loaded allograft; prosthesis)
Results
Methods
Retrospective case series between July 2009 and November 2011 (Tab. 1; [1])
Cancellous allograft was used to augment plate fixation of the fractures
Inclusion criteria
1.
Varus displaced two-part fracture (AO A2.2; >45°, unstable eroding subsidence, impression of the shaft into the head)
2.
Interval between injury and surgery between 1 and 8 weeks following an initial trial of conservative treatment
3.
Implantation of a structural bony allograft
4.
High-risk patient
5.
Patient noncompliance
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Tab. 1
Patients demographics and concomitant diseases
Patient no.
Gender
Age (years)
Dominant arm injured
BMI
Varus angle pre-op (°)
Follow up (months)
Risk factors
ASA score
Comments
1
F
73
No
22.5
50
36
CA, CT, OP, MA
3
Pulmonary emphysema, breast cancer
2
F
62
Yes
34.6
46
24
CA, CT, MD
4
Seizures
3
F
78
No
22.2
45
27
CA, OP, DM
4
Pancreatitis
4
F
67
Yes
20.8
51
29
CA, OP
2
5
F
52
Yes
24.1
52
48
CT, CA, OP, PI
2
6
M
57
Yes
38.1
45
36
DE, DM, AH
3
Plexus injury (resolved)
7
M
67
No
21.1
57
41
CA, CT, DM, AH, CL
3
Chronic liver disease (Child–Pugh B)
8
F
64
Yes
25.3
58
25
CA, OP, DM
3
9
F
56
Yes
27.5
59
28
CT, PI
3
10
F
62
Yes
21.2
46
24
CA, PE, DM
3
Polyarthritis
Median
63.0
23.3
50.5
28.5
3
ASA American Society of Anesthesiologists; Pre-op preoperative; CA chronic alcohol abuse; CT chronic tobacco abuse; OP osteoporosis; MA malignoma; MD multiple drug abuse (psychotropics); PI psychotic illness; DE severe depression; AH arterial hypertension; CL fibrotic or cirrhotic liver disease, BMI body mass index
Flexion −13 %, abduction −14 %, external rotation −15 %, compared to the uninjured contralateral side
Median abduction power 64 % of the uninjured side
Median varus displacement 51° (range 45–59°) preoperatively, 4° (range −5 to 19°) intraoperatively, 13° (range 1–18°) at the time of the final follow-up
Improvement of 38°
Tab. 2
Individual results
Patient
no.
Constant–Murley score
Pain (VAS)
Time to surgery (weeks)
Follow-up (months)
Flexion (°)
Bony union
Abduction (°)
External rotation (°)
Abduction power (% of uninjured side)
Varus angle intra-op (°)
Varus angle post-op (°)
1
83
0
1
36
170
Yes
120
50
79
15
16
2
48
4
2
24
90
Yes
90
45
63
2
9
3
84
0
3
27
170
Yes
120
50
89
10
18
4
64
2
3
29
140
Yes
100
35
67
5
15
5
86
0
1
48
170
Yes
120
50
53
19
21
6
84
0
6
36
160
Yes
110
40
58
0
5
7
45
7
2
41
130
No
80
30
100
−5
–
8
80
0
6
25
160
Yes
120
50
43
−3
11
9
55
5
7
28
140
Yes
80
35
39
5
7
10
58
2
8
24
150
Yes
90
40
40
3
14
Median
72.0
1
3.0
28.5
155
105
43
60.5
4
12.5
VAS Visual Analog Scale; Intra-op intraoperative; Post-op postoperative
Compliance with ethical guidelines
Conflict of interest
S. A. Euler, F.S. Kralinger, C. Hengg, M. Wambacher, and M. Blauth state that there are no conflicts of interest.
Study number 5105 approved by the ethics committee of the Medical University of Innsbruck on 16 May 2013.
Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
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