Proximal Humeral Fractures: Why My Practice Has Changed
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1 Proximal Humeral Fractures: Why My Practice Has Changed Clifford B. Jones, MD FACS The CORE Institute Banner University Medical Center University of Arizona Orthopaedic Residency Program Phoenix AZ Proximal Humeral Fractures: Why My Practice Has Changed Clifford B Jones, MD My disclosure is in the AAOS Final Program Book. No potential conflicts with this presentation Proximal Humeral Fractures: What Does Evidence Based Medicine Tell Us? Conclusion: Do NOT operate Majority Unable to Determine Which Implant is Best Tailor: Patient Expectations Fracture Pattern Surgeon Skill/Experience 1
2 Epidemiology (Court Brown, 2006) Common 6% of all fx with age, F:M 3:1 Majority LE Fall 87% Displacement Parts (Neer, 1970) 50 85% min displaced Muscle forces Problems Rotator cuff Short segment Osteoporosis Solutions Non op CRPP Ex Fix ORIF IMN Arthroplasty The Fracture The Problem Function Activities of Daily Living (ADL) Pain Tolerable, Sleep Healing Fracture Union Patient Expectations Hippocratic Oath: Do no harm Oxymoron? The Solution 2
3 Implants Percutaneous Pinning Arthroplasty Cloverleaf plate Periarticular plate Blade plate Custom Blade plate Locking Plate Intramedullary Nail (IMN) Stable Pattern Minimally Displaced No Dislocation Non Operative Tx fractures with minimum displacement, regardless of the number of fracture lines, can be satisfactorily treated by early functional exercises. Neer
4 54M, 4-Part with Marginal Impaction Manual Laborer High Expectations Young Physiologically 2 year Follow up 50M Open 4 Part/Shaft Manual Laborer High Expectations Young Physiologically 4
5 Literature 133/61,306 (0.2%) Citations Relevant 12/133 (9%) Inclusion 650 pts 3:1 F:M, 65 yo Neer Parts: 1 pt (49%), 2 pt (25%), 3 pt (21%), 4 pt (5%) Healing 98% ROM: 5/12 studies FF 139, ER 48, IR 52 Outcomes: variable Constant (6/12) 74 (fair) Complications: Varus 13%, AVN 2% 1 & 2 Part Healing 100% Constant 74 AVN 0.06% Comparison 3 & 4 Part Healing 96% Constant 67 AVN 5% Complications 48% Varus 23% AVN 14% w/ 4 Pt Operative Intervention Healing 98% Why Operate 1 & 2 Part Fx Complications 70%, AVN 8%, Screw Cut Out 12%, reop 14% 3 & 4 Part High Complications any treatment 5
6 3 & 4 Part 1997: Older Implants, Not Fixed Angle Average Age 74 F/U: 1 & 3 Yr Fracture Reduction/Malunion Outcome/Function Fracture Reduction = Xray Quality 2012: Newer Implants, Fixed Angle Average Age 60 F/U: 1 Yr Fracture Reduction/Malunion Outcome/Function Fracture Reduction = Xray Quality 6
7 Hemi > Non Op = Pain Hemi = Non Op: Function Non Op = Hemi Arthroplasty 3 & 4 Part Fractures Patients 340 Joint Preservation = ORIF Fracture Reduction ORIF > Arthroplasty Constant Age, Fx Pattern, Complications Outcome 7
8 RSA > HA: Constant Score HA > RSA: Complications RSA = HA: SF-36 8
9 Pubmed & Embase database articles outcomes & quality 2155 patients Grouped into Neer Classification Quality scores 15/48 Lack randomization, comparisons, independent evaluation inability to produce clinical conclusion 9
10 Neer Outcomes 2 & 3 Part 3 & 4 Part Pain Ratings 2 & 3 Part 3 & 4 Part 10
11 Complications ~ 20% FF & ABD = 100 Range of Motion IR & ER = 25 Conclusions Wide variation of treatments Quality of evidence low Does not support any treatment choice Operatively Obtaining & Maintaining reduction very difficult esp. with elderly patients with osteoporotic bone 11
12 Cochrane Database 2012 Handoll HHG, Ollivere BJ, Rollins KE 23 Small Randomized Studies 1238 Pts Conservative (Non operative) 8 Studies Timing of PT: early, late, none = results Pain: Sling > Body Bandage Op vs Non Operative 6 Studies Results = 1 yr,?op > 2 yr (DASH) Op > Non complications (1:9 Op with 2 ) Op vs Op 7 Studies Results equivocal Timing of PT: early vs late, no difference Non Operative Any early immobilization = Timing & Type of therapy = Probably Operative No clear better method Better 2 yr Risk higher & worse complications 12
13 79F 2 Part Fracture 72F 3 Part Fracture 78F 2 Part Fibular Strut Locked Plating 13
14 Complications Prominent HW Devascularization/A VN Technique Nonunion/Malunion Catastrophic Failure Atrophy/Scarring Implants Percutaneous Pinning Arthroplasty Cloverleaf plate Periarticular plate Blade plate Custom Blade plate Locking Plate Intramedullary Nail (IMN) Proximal Humeral Fractures Appropriate Fracture Selection 1 & 2 Part Non Op Old vs Young Demands Associated Injuries 3 & 4 Part High Complications Probably Operative in Younger Unknown Best Implant Locked Plating Not Panacea Skilled Experienced Surgeon Extremely High Reoperation & Complications Appropriate Therapy Non op: Wait until pain manageable Operative: Aggressive when able 14
15 Thank You 15
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