Proximal humerus fracture - dislocation

The following case is a patient that was seen in the office after a fall from height. He is a 25 year old male who presented with pain to his R shoulder in the  ER and diagnosed with a proximal humerus fracture dislocation. Closed reduction performed by the ER physicians. He seen in our office and reported pain to the R shoulder, denied elbow or hand pain, denied numbness or tingling to the hand.

The preop images demonstrate a significant size greater tuberosity fracture with comminution. Most shoulder surgeons will agree that an anterior traumatic shoulder dislocation as demonstrated in this case is associated with a Hill Sachs lesion and that a fracture of the great tuberosity is rare.

This patient underwent ORIF of the fracture through a deltopectoral approach without detachement of the deltoid. The alternative approach would have been an extensile U shaped incision just lateral to the acromion with a takedown of the deltoid to access the posterosuperior aspect of the humeral head where the fracture is most often located. The disadvantage of this approach is that detachment of the deltoid can cause malfunction of the muscle in addition to higher chances of axillary nerve damage. We selected to use a 3.5 reconstruction plate because it can be contured intraoperatively to match the anatomy of the patient and be positioned in the posterolateral aspect of the humerus where a "typical" locking plate would have been ideal for a lateral side application. In addition, the cost of that plate is significantly less compared to a locking proximal humerus plate.

In this case there were avulsion fractures of the infraspinatus and supraspinatus that required buttressing of these fractures in addition to the repair of the tendon to bone (rotator cuff) with Fiberwire non absorbable sutures.

The glenoid component in total shoulder replacement

Over the course of the past 30 years there have been a lot of different implant designs introduced in the treatment of arthritis of the shoulder. Although most would think that the new implants will have better longevity it seems that this is not true. Based on the largest meta-analysis performed as of today (1) The survivorship of the glenoid component has not changed the past 30 years (data from 1976-2007) (2) Implant design does not affect the longevitity of the prosthesis (13 different implant designs examined) (3) American Shoulder and Elbow Society surgeon membership did not influence the results either

However, the pegged all polythelene glenoid components outperform the keeled in terms of survivorship (see  reference 1) and the metal backed glenoid components fail more often and by different modes compared to all polyethylene glenoid components (in print unpublished data).

Reference 1: http://www.ncbi.nlm.nih.gov/pubmed/24352774

On the modes of failure of the glenoid: http://www.ncbi.nlm.nih.gov/pubmed/18381328

Review on the evolution of the design of the glenoid component: http://reviews.jbjs.org/content/1/2/e2

We prefer to use the all polyethylene pegged cemented glenoid components which allow bone ingrowth at the fenestrations of the central peg. After drilling the hole for the central peg of the glenoid the bone removed is used as bone graft for the central peg.

The radiographs below demonstrate that at 4 months postop there is bony ingrowth at the fenestrations of the central peg and no radiolucent lines.

Radiographically at 10 years 50% of the glenoid components are loose. However the revision rate is low at that point and most of the glenoids "survive" to 10-15 years if the end point is considered to be revision for glenoid failure.

The fading diagnosis: "Shoulder Impingement Syndrome"

What is a syndrome? A syndrome can refer to the traits that suggest the presence of a disease, or indicate a greater likelihood of developing the disease.The term syndrome derives from the Greek σύνδρομον, meaning "concurrence". In medicine and psychology, a less specific definition of syndrome is used, which describes a collection of symptoms and findings without necessarily tying them to a single identifiable pathogenesis. The more specific definition employed in medical genetics describes a subset of all medical syndromes.

The term impingement syndrome was initially introduced by Dr Charles Neer to describe a wide range of pathologies of the shoulder that presented with similar symptoms and was impossible to differentiate with the use of clinical tests and plain x-rays. The assumption is that the anteriorinferior aspect of the acromion and bone spurs that form in that area can cause rotator cuff tears or tendinosis. Of note at the time of introduction of this term there was no arthroscopy, no magnetic resonance imaging and no ultrasound of the musculosketal system. Partial thickness tears, rotator cuff tears, tendinosis of the supraspinatus and posterior capsular tightness can now be diagnosed more accurately. We suggested to make every effort to establish a diagnosis and avoid using the term impingement syndrome.  

The clinical tests used to diagnose impingement syndrome are performed with the arm abducted or forward flexed more than 90 degrees. The following video shows that with the pull of the supraspinatus the "footprint" of the rotator cuff clears the anterior-inferior area of the acromion or otherwise known as the area of shoulder impingement, at significantly lower angles of rotation of the arm (video from University of Washington, Department of Orthopaedics, for more information see shoulderarthritis.blogspot.com)

The following animations demonstrate the position of the arm during the most commonly used clinical tests established for the diagnosis of "impingement syndrome". The 3D animation is a simulation of a shoulder that was reconstructed from at CT scan of a patient diagnosed with the so called "impingement syndrome". For more information please read: http://www.ncbi.nlm.nih.gov/pubmed/22005869

Published evidence relevant to the diagnosis of impingement syndrome of the shoulder.

Papadonikolakis A1, McKenna M, Warme W, Martin BI, Matsen FA 3rd. J Bone Joint Surg Am. 2011 Oct 5;93(19):1827-32.

The Shape of the endosteal canal of the humerus. It is not a cylinder and definitely it is not straight. Implications for total elbow and shoulder replacement

The humeral canal proximally is not straight while all shoulder stems are straight. Aggressive reaming during total shoulder replacement for a "good fit" of the implant in the canal will lead to asymmetric removal of the endosteal bone and thinning which can result in loss of cortical thickness are certain areas and eventually at areas susceptible to fracture.

Supracondylar region of distal humerus. From oval the humeral canal changes to triangular. See previous post for clinical implications of distal humeral anatomy.

Intramedullary Fibular and Impaction Allografting in Revision Total Elbow Arthroplasty With Endosteal Deficiency

One of the many reasons for failed revision elbow replacement is loss of the normally irregular shape of the endosteal surface leading to reduced ability to provide rotational control of the humeral or ulnar component within the intramedullary canal. The endosteal bone loss of the distal humerus or proximal ulna compromises the rotational stability of the stem in the intramedullary canal. In these cases, impaction cancellous allografting techniques, similar to the ones used in revision total hip arthroplasties, are commonly used to address the osseous deficiency, but these methods are not optimal for providing rotational control of the prosthetic stem. We describe a technique of restoring the irregular shape of the endosteal bone using intramedullary fibular allografting to enhance the rotational control of the prosthetic stem within the intramedullary bone canal. 

For more information please go to: http://www.ncbi.nlm.nih.gov/pubmed/22370364

Stress fractures after reverse shoulder replacement

Stress fractures after reverse shoulder replacement is a problem that has to be recognized and accurately diagnosed early. The reported rate is 3-5% and the factors leading to this complication are (1) Over-lengthening of the arm (2) Advanced age at the time of surgery or osteopenia (3) Usually there is minor accident involved. Most of these fracture occur at the acromion while it is not uncommon to see them at the scapula. It is a problem that if left untreated can lead to displacement of the acromion, loss of tension of the deltoid and poor outcome. Usually the patient will stop using the shoulder and will present with "global" or posterior shoulder pain without any obvious explanation. Some surgeons do immobilize with shoulder in a sling for a period of 6 weeks if the X-rays are negative for a fracture. In my opinion, advanced imaging in the form of CT scan is required to see where the fracture is located. The value of the CT lies on the type of approach that will be selected for the treatment of this complication. The following case (one of my patients) demonstrates the workup of this condition in the setting of negative X rays. The patient regained all of his motion after a 6 week period of strict immobilization in a sling and the fracture did not displace. In addition, please note the position and length of the central locking baseplate screw of this system (glenoid side).

CT 3D reconstruction of the shoulder better demonstrates the acromial stress fracture (reconstruction performed with Osirix software)

Reverse shoulder replacement for proximal humerus malunion

This case highlights the value of the reverse shoulder arthroplasty in treating shoulder problems that were very difficult to solve in the past. There are still orthopaedic surgeons who believe that the reverse shoulder replacement is not a "good" implant due to the complications that is associated with. One must take into account that the implant design has improved since the introduction by Paul Grammont and also that the reverse shoulder replacement in the setting of revision surgery is a technically challenging operation that requires a surgeon experienced in revision shoulder surgery. While it is important to be conservative in the indications for surgery on the other hand is also important to be open minded to new ideas and implants and instead of rejecting new ideas rather examine them critically. Of note when Paul Grammont introduced the reverse shoulder replacement he was seen in a negative way by his peers and most of the surgeons at that time though that "reversing the anatomy" of the shoulder was nothing more than an extreme suggestion bound to fail due to the shear forces at the glenoid. The following case demonstrates the value of reverse shoulder replacement in salvaging difficult problems of the shoulder.

This is a 75 y/o F with a 35 year old malunion of the proximal humerus and shoulder active forward elevation (FE) to 25 degrees. She was neurovascularly intact at presentation with a functioning deltoid muscle and significant pain with active FE. She underwent a reconstruction to a reverse and her active FE was to 100 degrees at 4 months without pain. The technical tip for his operation was the "in situ" humeral cut that allowed dislocation of the shoulder. The insitu humeral cut is always conservative to preserve bone stock at the proximal humerus and if needed is revised to a more aggressive cut after the dislocation of the shoulder.

Preop AP and Grashey view (unable to obtain axillary due to stiffness)

Preop CT scan for templating

Intraop images with trial components in place

Immediate postoperative image