SRI SIDDHARTHA MEDICAL COLLEGE,TUMKUR DEPARTMENT OF ORTHOPAEDICS

Topic:

Factors that influence reduction loss in proximal humerus fracture surgery

MODERATOR:DR. JK REDDYPROFESSOR & HODDEPT. OF ORTHOPAEDICS

PRESENTER:DR. JAIPALSINH MAHIDAJR. RESIDENT (M.S

ORTHO) DEPT. OF ORTHOPAEDICS

INTRODUCTIONProximal humerus comprises 4 main osseous segments

1. Humeral head2. Lesser tuberosity3. Greater tuberosity4. Humeral shaft

Proximal humerus fractures account upto • 45% of all humeral fractures• 4-5% of all fractures in body

Blood supply to proximal humerus depends on• Anterior circumflex humeral artery• Posterior circumflex humeral artery

Fracture occurs more commonly in elderlyhigh energy trauma (fall on outstreached hand) is cause In young patientsDisplacement of fracture segments due to muscle pull• Greater tuberosity – superiorly & posteriorly by supraspinatus• Lesser tuberosity – medially by subscapularis• Humerus shaft – adducted medially by pectoralis major• Proximal fracture fragment – abducted by deltoid

Primary goal for surgical treatment for displaced proximal humerus fractures• Restore shoulder function improve active motion, strength & function

• Bone union with good alignment with various treatments

Proximal humerus locking plate osteosynthesis - gold standard surgical treatment • deltopectoral approach which is minimally invasive & preserves circumflex artery

Restoration of medial support – proven to be important factor for good functional outcome

Previous biomechanical study showed• angular LCP

• Most rigid under 3 load tests Varus bending, medial shearing & axial torque

• Could resist physiological loads encountered in osteoporosis

Despite these improvements, complications have been described• Implant related problems (screw perforation, loosening, plate impingement, metal failure)• Reduction loss• Humeral head osteonecrosis• Non union• infection

Most common cause of re-operation • Implant related problems • Reduction loss

• 4.2-13.7% • Results from old age, osteoporosis, severe comminution, technical error, patient non-

compliance• complications results in poor functional outcome

This study hypothesized All variables (age, gender, hypertension, diabetes mellitus, mechanism of

injury, bone mineral density, neer& ota fracture type, neck-shaft angle, medial comminution, surgical approach or medial support) influenced reduction loss & identified risk factors of reduction loss after lCP fixation of proximal humerus.

classification

In 1886, Kocher T. was the first one to devise a classification of proximal humeral fractures. His classification was based on anatomical levels of fractures :

Anatomical neckEpiphyseal regionSurgical neck.

Kocher classification

In 1955 Watson-Jones classified fractures of upper end of humerus into Abduction and Adduction types, depending on the mechanism of injury

In 1934, Codman EA classified upper end humerus fractures into four distinct fragments, occurring roughly along the anatomical lines of epiphyseal union • He was able to differentiate four major fragments: the anatomical head, the greater tuberosity, the lesser tuberosity, and the shaft. Codman's conclusion was that all fractures were some combination of these different fracture fragments

Codman classification

. In 1970 Neer CS, based his four-part classification of upper end humerus on Codmans classification. This was the first truly comprehensive system that considered the anatomical and biomechanical forces resulting in the amount of displacement of fracture fragments and related these factors to diagnosis and treatment. It is the most commonly used classification for proximal humeral fractures• When any of the four major segments is displaced greater than 1 cm, or

angulated more than 45°, the fracture is considered displaced. Fissure lines or hairline fractures are not considered displaced fragments. A fragment may have several undisplaced components: these should not be considered separate fragments since they are in continuity and are held together by soft tissue.

• Neer has also emphasized the term fracture-dislocation Fracture dislocations can be classified according to direction (anterior or posterior) as well as to

the number of fracture fragments (two-part, three-part or four-part).• Head-splitting fractures and impression fractures of the articular surface are special fracture

Neer’s Classification

AO CLASSIFICATION • 11A – extra-articular, unifocal fracture

11A-1 :- greater tuberosity11a-2 :- surgical neck metaphysis impacted11a-3 :- surgical neck metaphysis not impacted

• 11b – extra-articular, bifocal fracture11b-1 :- three part surgical neck, metaphysis impacted11b-2 :- three part surgical neck, metaphysis not impacted11b-3 :- extra-articular fracture with glenohumeral dislocation

• 11c – articular fracture11c-1 :- slight displacement11c-2 :- marked displacement11c-3 :- with glenohumeral dislocation or head-split

Patients and methods Included 285 patients treated with locking plate between January

2004 – December 2011.All operation performed by a single surgeon.Standardised x-ray (true AP and axillary lateral view) were used to

evaluate neer ao ota fracture type, initial nsa (varus displacement), medial comminution, post operative nsa (reduction adequacy), medial support restoration, healing progress, reduction loss, implant related problem immediately after surgery and at 2 weeks, 1month, 3 months , 6 months, 9 months and atleast 1year after surgery.

Surgical indication based on neer classification • SHOULDER JOINT FRACTURE WITH DISLOCATION >10mm DISPLACEMENT OF

FRACTURE FRAGMENT, 5MM DISPLACEMNT OF GT, ANGULAR DISPLACEMENT >450 ANGLE, OR LOSS OF MEDIAL METAPHYSEAL COLUMN.

EXCLUSION CRITERIA • NON-DISPLACED / MINIMALLY DISPLACED WITH STABILITY.• OPEN FRACTURE AND PATHOLOGICAL FRACTURE

7 PATIENTS DIED, 15 PATIENTS LOST TO FOLLOW UP AND 3 PATIENTS REFUSED TO PARTICIPATE

FINALLY 252 PATIENTS(49 MAN, 203 WOMAN) INCLUDED IN THE STUDY

AVERAGE AGE 62.1( 25-92 YEARS )

PATIENTS DIVIDED INTO 2 GROUPS

REDUCTION LOSS REDUCTION MAINTENANCE

1. INCLUDED 17 PATIENTS (AVERAGE AGE 68.2±12 YEARS)

2. >100 ANGULATION IN ANY DIRECTION 3. >5MM HEIGHT LOSSOF HUMERAL

HEAD FROM PLATE 4. FIXATION FAILURE

1. INCLUDED 235 PATIENTS (AVERAGE AGE 61±12.4 YEARS)

2. 100 ANGULATION IN ANY DIRECTION 3. <5MM HEIGHT LOSSOF HUMERAL

HEAD FROM PLATE 4. NO FIXATION FAILURE

MECHANISM OF INJURY DIVIDED INTO

NSA WAS THE ANGLE BETWEEN LINE PERPENDICULAR TO LINE FROM SUPERIOR TO INFERIOR BORDER OF ARTICULAR SURFACE AND A LINE BISECTING HUMERAL SHAFT• NORMAL NSA 1300 (RANGE, 120-140 DEGREES)• POST OPERATIVE NSA 120-1400 INDICATED ADEQUATE REDUCTION • NSA <1100 – DISPLACED VARUS FRACTURE

HIGH ENERGY TRAUMA LOW ENERGY TRAUMA

FALLING FROM HEIGHT HIGHER THAN STANDING HEIGHT, MOTOR VEHICLE ACCIDENT, DIRECT BLOW.

RESULT OF FALLING FROM STANDING HEIGHT OR LESS

MEDIAL COMMINUTION WAS DEFINED AS ATLEAST 1 BONY FRAGMENT IN MEDIAL SURGICAL AREA OR LOSS OF MEDIAL METAPHYSEAL COLUMN.• 3D CT WAS USED TO CONFIRM MEDIAL COMMINUTION AND ARTICULAR

INVOLVEMENT.FUNCTIONAL OUTCOME WERE EVALUATED WITH VISUAL ANALOG

SCALE FOR PAIN AND CONSTANT SORE AT FINAL FOLLOW-UP

SURGICAL TECHNIQUEUNDER GA PATIENT IN SUPINE POSITION IN DELTOPECTORAL APPROACH• 10-15CM SKIN INCISION FROM CORACOID PROCESS TO DELTOID INSERTION • DISSECTION BETWEEN DELTOID AND PECTORALOS MAJOR TO INCISED

FASCIA AND EXPOSE FRACTURE SITE• CARE TAKEN TO AVOID INJURY TO AXILLARY NERVE AND CIRCUMFLEX

ARTERY • AFTER OPEN REDUCTION, 3-5 HOLE LCP FIXED

IN MINIMALLY INVASIVE (DELTOID SPLITTING) APPROACH• 4-5 CM SKIN INCISION FROM ACROMION EXTENDING DISTALLY • AFTER INDIRECT REDUCTION 3-5 HOLE PLATE FIXATION PERFORMED

PHILOS PLATE WAS USED IN ALL CASES FROM MAY 2009 MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS WAS

PREFERRED PROCEDURE EXCEPT IN CASE OF AO TYPE C3SHOULDER WAS IMMOBILISED FOR 1-2 WKS POST OP. GENTLE PASSIVE MOTION OF SHOULDER STARTED AS SOON AS

PATIENT WAS COMFORTABLE.ACTIVE MOTION OF ELBOW, WRIST AND HAND BEGUN ON 1ST POST

OPERATIVE DAY.ACTIVE SHOULDER MOVEMENT STARTED AT 4-6 WKS STRENGHTENING EXERCISE STARTED AT 12 WKS

RESULTS COMPLICATIONS • 20 IMPLANT RELATED PROBLEMS (SCREW-PERFORATION, PLATE

IMPINGEMENT, CUT-OUT, CUT-THROUGH, PLATE FAILURE) – 7.9%• 17 REDUCTION LOSS - 6.7% • 5 AVASCULAR NECROSIS - 2%• 5 NON-UNION - 2% • 3 AXILLARY INJURY - 1.2% • 3 INFECTIONS -1.2%

VISUAL ANALOG SCALE SCORE IN REDUCTION LOSS GROUP WAS NOT SIGNIFICANTLY DIFFERENT FROM REDUCTION MAINTENANCE, BUT CONSTANT SCORE IN REDUCTION LOSS WAS SIGNIFICANTLY DIFFERENT FROM REDUCTION MAINTENANCE

OUT OF 17 REDUCTION LOSS, 13 UNDERWENT CONVERSION SURGERY TO ARTHROPLASTY AND 4 UNDERWENT REVISION SURGERY FOR PLATE REFIXATION AND AUTOGENOUS BONE GRAFT FROM PELVIC ILIUM

IN 15 CASES, ACUTE REDUCTION LOSS OCCURRED WITHIN 1 MONTH AFTER SURGERY

IN 2 CASES, LATE REDUCTION LOSS WITH SCREW PERFORATION OR LOOSENING OCCURRED AT 3-6 MONTHS

REDUCTION LOSS AND REDUCTION MAINTENANCE DID NOT DIFFER IN TERMS OF GENDER, HYOERTENSION , DIABETES, MECHANISM OF INJURY, NEER OR OTA FRACTURE TYPE, DELTOPECTORAL APPROACH

REDUCTION LOSS REDUCTION MAINTENANCE

1. AGE OLDER (68.2±12YEARS) YOUNGER (61.02±12.4YEARS)

2.BMD LOWER (-2.8±0.7) HIGHER (-1.8±0.6)

3.INITIAL NSA LOWER (96.6±16.50) HIGHER (115.5±13.30)

4.RATE OF MEDIAL COMMINUTION

MORE COMMON (17 OF 17) LESS COMMON (118 OF 235)

5.POST OPERATIVE NSA LOWER (123.6±15.60) HIGHER (130.6±8.30)

6.INSUFFICIENT MEDIAL SUPPORT

MORE COMMON (15 OF 17) LESS COMMON (27 OF 235)

UNIVARIABLE REGRESSION ANALYSIS REVEALED THAT AGE, OSTEOPOROSIS, VARUS DISPLACEMENT, MEDIAL COMMINUTION, REDUCTION ADEQUACY AND INSUFFICIENT MEDIAL SUPPORT HAD SIGNIFICANT CORRELATION WITH REDUCTION LOSS

MULTIVARIABLE LOGISTIC ANALYSIS REVEALED THAT OSTEOPOROSIS, VARUS DISPLACEMENT, MEDIAL COMMINUTION , INSUFFICIENT MEDIAL SUPPORT WERE INDEPENDENT RISK FACTORS FOR REDUCTION LOSS

DISCUSSION THANASAS ET AL. REVIEWED 12 STUDIES WITH 791 PATIENTS

• REPORTED RE-OPERATION RATE WAS- 13.7%• MOST COMMON CAUSE FOR RE-OPERATION

• REDUCTION LOSS- 31%• AVN- 21%• IMPLANT FAILURE- 20%

SPROWL ET AL. REVIEWED 12 STUDIES WITH 514 PATIENTS • COMPLICATION RATE WAS - 49%• RE-OPERATION RATE – 14%• MOST COMMON COMPLICATION

• VARUS MAL UNION - 16%• AVN- 10%• SCREW PERFORATION - 8%

KRAPPINGER ET AL. REPORTED THAT BONE QUALITY, BIOLOGICAL AGE, ANATOMICAL REDUCTION AND MEDIAL CORTICAL SUPPORT INFLUENCE SUCCESSFUL SURGICAL TREATMENT AND RECOMMENDED PRIMARY ARTHROPLASTY SHOULD BE CONSIDERED IF ANATOMIC REDUCTION AND RESTORATION OF MEDIAL CORTICAL SUPPORT CANNOT BE ACHIEVED

FOR MOST FRACTURE REDUCTION LOSS IS MORE COMMON AMONG OLDER PATIENT

POST OPERATIVE NSA CAN ALSO INFLUENCE RISK OF REDUCTION LOSS • AGLUDELO ET AL. REPORTED 30.4% INCIDENCE OF LOSS OF FIXATION IN CASES

WITH VARUS MAL REDUCTION AND 11% INCIDENCE IN CASES WITH POST-OPERATIVE HEAD SHAFT ANGLE >1200

• IN CURRENT STUDY, REDUCTION LOSS OCCURRED IN 6 CASES WITH POST OPERATIVE VARUS POSITION (6 OF 17) AND IN 11 CASES WITH POST OPERATIVE ADEQUATE POSITION (11 OF 235)

REDUCTION LOSS DID NOT OCCUR MORE FREQUENTLY WITH DELTOPECTORAL APPROACH (11 OF 147) THAN WITH MINIMALLY INVASIVE APPROACH (6 OF 104)• DESPITE MANY FAVOURABLE CLINICAL OUTCOME MINIMALLY INVASIVE APPROACH

WAS NOT SUPERIOR AND SHOULD NOT BE EXAGGERATED IN TERMS OF REDUCTION LOSS

OSTEOPOROSIS WIDELY ACCEPTED RISK FACTOR FOR REDUCTION LOSS • MANAGEMENT OF OSTEOPOROSIS MAY REDUCE INCIDENT OF FRAGILITY FRACTURE

AND COMPLICATION OF FRACTURE TRETAMENT• REDUCTION LOSS MAY BE BECAUSE OF POOR BONE QUALITY • HYMES ET AL. REPORTED CANCELLOUS BONE DENSITY AND TOTAL CANCELLOUS

SCREW DEPTH PENETRATION WERE CRITICAL VARIABLES • MATASSI ET AL. REPORTED USE OF LOCKING PLATE WITH FIBULAR GRAFT

AUGMENTATION IS A SAFE AND RELIABLE TECHNIQUE TO SUPPORT HUMERAL HEAD

• ANGULAR STABLE OPEN REDUCTION AND INTERNAL FIXATION ARE ASSOCIATED WITH HIGH COMPLICATION AND REVISION RATES AMONG OSTEOPOROTIC PATIENTS SO PRIMARY HEMI ARTHROPLASTY IS SUITABLE OPTION • THE BMD DATA CAN INFLUENCE DECISION TO PERFORM OSTEOSYNTHESIS

VERSUS ARTHROPLASTY FOR PROXIMAL HUMERUS FRACTURE IN CURRENT STUDY, DISPLACEMENT OF HUMERAL HEAD INTO VARUS

ALIGNMENT WAS ASSOCIATED WITH A HIGHER FAILURE RATE THAN VALGUS OR NEUTRAL WHICH SUGGEST FRACTURE WITH VARUS ALIGNMENT ARE MORE LIKELY TO DISRUPT MEDIAL BUTTRESS AND BE UNSTABLE

MEDIAL COMMINUTION IS INDEPENDENT RISK FACTOR FOR REDUCTION LOSS• OSTERHOFF ET AL. REPORTED THAT CALCAR COMMINUTION WAS RELEVANT

AND EASY TO DETECT PROGNOSTIC FACTOR

COMBINED CASES OF INITIAL VARUS DISPLACEMENT AND MEDIAL SIDE COMMINUTION HAVE HIGH RISK OF REDUCTION LOSS FOR PROXIMAL HUMERUS FRACTURE, SO INFERIOMEDIAL SCREW FIXATION AND RESTORATION OF MEDIAL SUPPORT BY CORTEX TO CORTEX REDUCTION ARE MOST IMPORTANT FACTOR FOR PREVENTING REDUCTION LOSS

FROM SURGICAL POINT OF VIEW MEDIAL SUPPORT IS PROBABLY MOST IMPORTANT PROCEDURE FOR PREVENTION OF REDUCTION LOSS IN UNSTABLE PROXIMAL HUMERUS FRACTURE

LIMITATION OF THIS STUDY • INVOLVES SMALL NUMBER OF CASES OF REDUCTION LOSS • MOST OF MEASUREMENTS SHOWED GOOD RELIABILITY BUT SOME ONLY

SHOWED FAIR RELIABILITY • SOME 4 PART FRACTURE OF NEER TYPE AND SOME B FRACTURE OF OTA WERE

INTERPRETED AS 3 PART AND TYPE C • WAS A RETROSPECTIVE STUDY

CONCLUSION REDUCTION LOSS ATER SURGICAL TREATMENT FOR PROXIMAL

HUMERUS FRACTURE OCCURRED AT RATE OF 6.7%MULTIVARIABLE REGRESSION ANALYSIS REVEALED OSTEOPOROSIS,

DISPLACED VARUS FRACTURE, MEDIAL COMMINUTION, INSUFFICIENT MEDIAL SUPPORT WERE INDEPENDENT RISK FACTOR FOR REDUCTION LOSS AFTER SURGERY FOR PROXIMAL HUMERUS.

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