Les séquelles traumatiques. Ph. Valenti, J. Kany, D. Katz
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1 Indications et Techniques Les séquelles traumatiques Ph. Valenti, J. Kany, D. Katz Paris Shoulder Unit Clinique Bizet (Paris, France)
2 Disclosures Arthroplasty Consultant : FH orthopaedics receive royalties Arthroscopy Consultant : Zimmer Biomet Arthrex
3 Sequeleas of proximal humeral fracture Complex challenge for any surgeon Clinical evaluation Radiographic analysis Treatment options Best treatment Good treatment!!! in emergency PREVENTION
4 Clinical evaluation History of the fracture Age, sexe, workercompensation Initial fracture (2/3/4 fragments / displacement/ Dislocation ) Initial treatment closed / open / ORIF/ Prothesis Delay since Initial treatment Infection
5 Clinical evaluation Pain VAS (0/10) Trophicity Deltoid Cuff (SSC, SS, IS) Range of motion Active (Lack AE ER IR) Passive SA impingement STIFF shoulder Constant / ASES / SST / SSV scores
6 Neurological evaluation Deltoid / SS IS atrophy Pseudo tinel EMG and nerve conduction study Axillary nerve Suprascapular nerve (violent trauma / displaced Fract)
7 Radiographic evaluation Standards X rays AP / Outlet / axillary views CT Scan +++ MRI Great tuberosity +++(cuff) Humeral Head (necrosis) Surgical neck Less tuberosity Soft Tissue(Cuff / deltoid/ LHB) Cartilage
8 Standards X Rays How to analyse Great tuberosity? Union :continuity with the diaphysis Non union : not healing > 6months Malunion : >5-10mm of displacement cuff dysfunction
9 Standards X Rays How to analyse Humeral head? Necrosis Impaction valgus Impaction varus Posterior dislocation Anterior dislocation
10 AVNecrosis after Functionnal treatment!!!!
11 Union Standards X Rays How to analyse surgical Neck? Non union :not healing >6months Malunion: Varus / valgus
12 Standards X Rays How to analyse less tuberosity? Union Non union :not healing > 6months Malunion: medial displacement with medial impingement less strength IR
13 CTScan versus MRI Better analysis bone deformity Quality of the bone Osteoporosis / density H Head / necrosis Cartilage wear (glenoid) Muscular Trophicity and degree Fatty degeneration Long head biceps
14 Therapeutic options Conservative Surgical
15 Malunion sometimes well tolerated NO sophisticated operation conservative treatment
16 Stiff shoulder No bone deformity Physiotherapy (injections) +++ Removal hardware Glenoid cartilage erosion Arthrolysis@ Anatomic TSA
17 Stiff shoulder bone deformity functionnal cuff GT malunion Osteotomy tuberositie Humeral head necrosis Hemiarthroplasty Anatomic TSA(glenoid cartilage wear) LT malunion Osteotomy
18 HH fracture sequelae classification Walch, Boileau, JSES, 2001 Type I: Cephalic collaps or Necrosis Type II: Locked dislocation or fracture dislocation Type III: Surgical neck non union Type IV: Severe tuberosity malunion
19 Type 1: impacted valgus/varus fracture cephalic collapse / necrosis Functionnal cuff +++ Osteotomy GT +H Head Hemiarthroplasty Anatomic TSA (glenoid wear) No osteotomy of the tuberosity if you arthroplasty ++
20 3 part fract Closed initial treatment Impacted valgus Malunion GT osteotomy
21 4 fragments Impacted valgus Fract 85 years old Pain AAE 80 ER1 40 Functionnal cuff Constant score 27 Malunion GT necrosis HHead
22 Constant score 68 No pain
23 72 years old 4 part fract Necrosis Glenoid cartilage wear Constant score 13
24
25 Type 2: chronic posterior dislocation (>6months) Functionnal cuff Hemiarthroplasty >12months AnatomicTSA (glenoid wear) Less retroversion
26 Chronic post dislocation man 63 years old Cst 51mths=47(57%)
27 final flexion at 9 years =170 Cst=78!!
28 Type 2: chronic anterior dislocation (>6months) Fracture dislocation No subscapularis Reversed prosthesis Contra indication Hemiarthroplasty
29 71 years old lady with a chronic ant dislocation Postop X ray Intact Posterior edge of the glenoid giving the good glenoid version for the definite implant Iliac crest graft in place with temporary K wires
30 Chronic anterior dislocation Hemiarthroplasty is not the good way!!!!
31 Type 3: surgical neck non union Cuff is functionnal Bone grafting(iliac creast) + plate Arthrolysis Cuff is no functionnal GT displaced Stiff shoulder Cartilage wear Osteoarthritis Reversed prosthesis
32 Non union surgical neck
33
34 Type 4: Fracture dislocation with non union GT No functionnal cuff No continuity GT with diaphysis Reversed P Reversed + Episcopo if lack of active ER
35
36
37 Shoulder arthrodesis Definitive paralysis of deltoid and cuff (good serratus anterior) Chronic infection Young man (type 4) Bone graft (iliac creast) Fibular vascularized graft
38 Sequelea of proximal humeral fracture neurologic lesion < 6 months Nerve graft Axillary +/- Suprascapular N 12-18months Neurotisation Radial triceps branch to axillary N Spinal to suprascapular nerve
39 Take home messages Great Tuberosity (GT) = cuff +++ FUNCTIONNAL CUFF Osteotomy Hemiarthroplasty (necrosis) Anatomic total arthroplasty (Glenoid wear) NO FUNCTIONNAL CUFF Reversed prosthesis
40
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