Should We Really be Performing HHR for Proximal Humeral Fractures Anymore?

Transcription

1 Should We Really be Performing HHR for Proximal Humeral Fractures Anymore? Anthony A. Romeo, MD Professor, Dept. of Orthopaedic Surgery Head, Section of Shoulder and Elbow Rush University Medical Center Chicago, Illinois

2 Disclosures: 1. Royalties: Arthrex, Elsevier 2. Consultant: Arthrex 3. Miscellaneous Support: Arthrex 4. Basic Science/Research Support: Arthrex, Smith and Nephew, Ossur, Miomed, DJOrtho, Conmed Linvatech, Athletico 5. Editorial Board: Orthopedics Today (Chief Medical Editor), Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow, Techniques in Sports Medicine, Sports Health, Orthopedics 6. Publisher Support: Elsevier, Orthopedics Today

3 Epidemiology Proximal Humerus Fractures (PHF) Third most common fracture 4-5% of all fractures , United States Data No increase in incidence of fractures 25% relative increase in operative fixation (29% inc in ORIF, 20% inc in HA) Bell JE et al, JBJS-A, 2011

4 Basis for Clinical Decisions Age Bone Quality Fracture Pattern Timing of Surgery Activity level Co-morbidities

5 Decision Making Fracture type + Osteopenia + Blood Supply Age Medial Hinge more for mechanical reasons, not vascular Can you achieve anatomic reduction with stable fixation? Problem of Active External Rotation

6 Treatment Options Non-operative Early ROM at 3 weeks Operative Percutaneous Pinning Suture Fixation Intramedullary Nailing ORIF Hemiarthroplasty Reverse Total Shoulder Arthroplasty

7 How do we decide? Pins, Plates, Arthroplasty

8 Timing of Surgery Ability to reduce fracture Viability of humeral head Ultimate functional outcome Untreated fracture > 4 weeks is chronic sequelae and no longer acute!!!

9 ORIF of Proximal Humeral Fractures When is it Great to Plate?

10 Plate / Suture Indications 2, 3 and 4 Part Fractures Age <65 y/o Combined cortical thickness > 4mm Viable head Unstable fx patterns involving medial calcar Consider 2 nd orthogonal plate to control rotation

11 Plate Fixation Issues with plate fixation Bone quality Osteonecrosis Screw cutout/hardware failure ORIF of proximal humerus fractures in elderly patients has failure rates from 13-20% Even with locking plate technology, loss of reduction can occur from 21-63%

12 Shoulder Replacement for Fractures When to replace???

13 Shoulder Arthroplasty for Fracture AGE: any BONE QUALITY: any FX PATTERN: ischemic head based on Hertel criteria TIMING: optimal timing 6-14 days after injury for hemiarthroplasty and tuberosity osteosynthesis

14 Prosthetic Replacement Three Basic Indications Unable to achieve adequate osteosynthesis Compromised vascularity Failed ORIF Examples Fracture dislocations Anatomic neck fractures Head splitting fractures Impression fractures >40-50% 3- and 4-part fractures, older pts

15 Hemiarthroplasty Reconstruction Considerations Challenge: Reconstruct the proximal humerus without anatomic landmarks

16 FAILURE OF FRACTURE ARTHROPLASTY Post-OP 6 Mo Post-OP RC-Deficiency

17 Three Major Challenges to Restore Anatomy Reconstruction of Center of Rotation - head size - prosthetic height Reconstruction of Tuberosities - length - position of the tuberosities - fixation technique Fixation of the Rotator Cuff

18 High Postioning

19 OVERSTUFFING THE JOINT Lateralization of the center of rotation Overtensioning of inferior capsule Loss of Abduction

20 Hemiarthroplasty for Fracture Pre-op Treated with Hemi Failed Inconsistent Reconstruction of Tuberosities!

21 Hemiarthroplasty vs. Nonoperative Rx Olerud P et al (JSES, 2011) Sweden RCT Hemiarthroplasty vs. Non-op for 4-part fractures Avg age 77 2 year follow-up HA better HRQoL, EQ-5D, DASH No difference in ROM Boons HW et al (CORR, 2012) Canada RCT Hemiarthroplasty vs. Non-op for 4-part fractures Age >65yo 50 pts, 1 yr follow-up No difference in Constant or SST

22 Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial. Boons HW, Goosen JH, van Grinsven S, van Susante JL, van Loon CJ. Clin Orthop Relat Res Dec;470(12): patients, randomized. We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment.

23 Hemiarthroplasty for Fracture Lanting JSES studies 2155 pts. No ability to produce clinical conclusions Petit JSES 2009 Surgeons cannot agree on PHFx treatment Koutras JBJS Br studies 810 HHR for Fx Pain gone in most, limitation of function persists Nijs Acta Orthop Belg 2009 Meta-analysis of HHR: frustrating

24 Hemiarthroplasty vs. ORIF Solberg et al (JBJS, 2009) 3 and 4-part PHFs 38 pts ORIF Locked Plate, 38 pts HA Mean 36 mo f/u Constant: ORIF 68.6, HA 60.6 (p<0.05) ORIF Higher complication rate (50% vs. 26%) Loss of fixation w/ varus angulation >20 deg Surgical treatment of three and four-part proximal humeral fractures. Solberg BD, Moon CN, Franco DP, Paiement GD. J Bone Joint Surg Am Jul;91(7):

25 Reverse Total Shoulder Arthroplasty For Proximal Humerus Fractures

26 Why Consider RTSA for Fracture? Unknown pre-injury status of the shoulder Constant Score lower in elderly and females Katolik JSES 2005 Yian JSES 2005 Incidence of RCTs increase with age Asymptomatic and Symptomatic > 60 yrs range 6% to 40% Cadaver, Ultrasound, MRI

27 Asymptomatic Factors Present > 75 yrs.-- 56% (RCT, stiffness, DJD) RCT 56% CV 33% Pulm 28% GI 25% DM 12% Depression 18% BMI < Increase of RCTs Scarlat Rev Chir Orthop 2005

28 Indications Severe fracture pattern (3 or 4 part, Head Split) Age over 70 Adequate glenoid bone and functioning deltoid Implant with bone ingrowth/adhesion potential Good contralateral upper extremity function

29 Contraindications Wheelchair bound Walker dependent Neurologic diagnosis Mentally not able to comply with aftercare Morbid obesity Fractures where the articular segment is not significantly involved: There are other options! This is your 1 st Reverse

30 Reverse prosthesis Advantages Recovery of active elevation is not influenced by tuberosity healing (Vertical) Although, Recovery of external rotation requires tuberosity healing (Horizontal)

31 Reverse Prosthesis Disadvantages Complications (25%) Instability Hematoma / Infection RSD RSP Long-term follow-up lacking Hemi

32 Reverse vs Hemiarthroplasty Reverse Hemi 76 Age months FU* 70 months 55 points Constant score 51 points 107 Active ant elevation Active external rotation* 21 4,6 pts Active internal rotation 5,4 pts

33 Platform Stem (Convertible)

34 HA vs. RSA Boyle MJ et al (JSES, 2012) 55 RSA, 313 HA for for acute PHF Mean Age RSA , HA year f/u Oxford Shoulder Score (OSS) RSA 41.5, HA 32.3 (p<0.05) No difference New Zealand Joint Registry Revision rate or 1-year mortality rate

35 -Level II prospective comparative study, HA vs. 24 RSA with minimum 2 year f/u -better ASES and SST scores in RSA group -better tuberosity healing in RSA group -better forward elevation in RSA group

36 -Level IV systematic review, studies, 377 RSA patients, 504 HA patients -Higher functional scores and forward flexion with RSA -More external rotation with HA

37 -Level III, retrospective cohort study, HA vs. 9 RSA vs. 9 ORIF - No significant differences in patient-related outcome measures - Better elevation with RSA - Better cost savings to Medicare with RSA

38 -Level IV retrospective review, RSA vs. 12 HA -RSA better for: -elevation -ASES scores -UPENN scores -SANE score

39 Motion after Prosthesis for PHFx Hemiarthroplasty with tuberosities healing

40 ICSS 2007 Motion after Prosthesis for PHFx Reverse prosthesis

41 Acute Proximal Humerus Fracture Pre-op Post-op

42 Motion after Prosthesis for PHFx Hemiarthroplasty with tuberosity problems

43 Summary RSA for PHF has better: restoration of FF patient-related outcomes cost-effectiveness

44 Systematic Review Purpose: Compare ORIF vs. CRPP vs. HA vs. RSA 3 and 4-part PHFs Hypothesis RSA will demonstrate best overall outcomes at minimum 1-year follow-up

45 Conclusions ORIF will usually be the best initial treatment Higher reoperation rate with ORIF HA and RSA both effective with no significant difference in outcomes or complication rate Age as covariate does not significantly change above conclusions

46 Future Directions Need for RCTs Comparison to Non-operative Tx Cost-effective analysis ORIF may be best initial treatment, but is it costeffective given reoperation and complication rates? Subgroup analyses based on age RSA vs. ORIF for patients >70yo vs. <70 yo

47 Thank you!

48 Thank You!