Transcript Rockwood chp. 22

Rockwood chp. 22
696-700
吳孟晃
Current Treatment Options
• Prevention-1
– Lesser tuberosity
• trial stems maintain in canal during glenoid
preparation
– Greater tuberosity: if substantial cysts
• Anteromedial approach->avoid torsional stress on
the tuberosity
– Coracoid process: rare
• re-suturing the fracture tip to the surrounding
tissues—pectoralis minor tendon and
coracoacromial ligament
Prevention-2
• Glenoid: extremely osteopenic (RA)
– Rest the retractor on the upper portion of the
axillary border of the scapula
• Humeral shaft
– Multiplanar preoperative x-rays with
magnification markers
– Preoperative templating
– Complete soft-tissue releases
– Anteromedial approach
Complete soft-tissue releases
• Subacromial and subdeltoid regions
• Contracture of the superior or posterior capsule
– surrounding the glenoid outside or above the biceps
anchor attachment and then along the glenoid rim
posteriorly
• Inferior shoulder joint contracture
– capsule release around the neck of the humerus >avoid axillary n. injury
• Anterior shoulder contractures:
– along the glenoid rim
Humeral canal preparation
• Prevent perforation
– Flexibility in the implant system
– Intraoperative x-rays for malunion
• Cortical defect:
– Bypassed by a stem >4 to 5 cm distal to the
defect
The anterolateral approach to the humeral shaft
• Extended distally from a
deltopectoral or
anteromedial shoulder
incision
• More distal portion of
the incision is used for
fracture reduction and
fixation
• Cephalic vein to fall
medially with the
proximal portion of
the incision
• Biceps is retracted
medially
• Brachialis is also
pushed medially
• The radial nerve at
lateral side
Intraoperative fracture
• Nondisplaced lesser tuberosity fractures
– Before routine placement of the trial
component
– Suture repair
• Greater tuberosity crack
– During implant placement
– Multiple large suture
• Glenoid fractures: rare
– Unable to implant glenoid component->bone
graft with head implant only
– Screw or plate if large enough
Humeral shaft fracture
• Stable stem + healed fracture
• Preoperative:
– Extensive osteolysis or nonunion-> bone graft
• Intraoperative: x-ray
– Oblique: noncemented long stem with
cerclage cables
– Transverse: cemented long stem+ allograft
•
Postoperative fx considerations:
1. Fracture location
•
Transverse fracture at the tip of the prosthesis
with displacement
2. Through bone or bone + cement
•
Fracture through bone and cement
3. Fracture alignment
•
Substantively displaced and unstable fracture
4. Implant fixation
5. Bone lysis
•
Displaced fracture with loose prosthesis or
osteolysis
6. Radial nerve palsy: controversial
•
2nd to persistent motion of fracture fragments
Fracture Location
• Type C: Distal to tip
– Nonoperative by functional brace
• Type B: At the tip
– Mostly fail to nonoperative
• Type A: proximal to tip
– Kumar et al: 2 union in 3 p’t
Comminuted proximal humeral
fracture with distal humeral extension
-> fail to union and osteolysis
long-stemmed humeral component
cemented distally and press-fitted
proximally with the addition of bone
bank allograft + wire
Humeral shaft fracture
with extensive osteolysis
and humeral component
loosening and nonunion
• Type C: 4/5 patients treated successfully
by functional bracing
•
Campbell et al
• Type C: 2/3 healed successfully with
nonoperative management
•
Kumar
• One fracture distal to the prosthesis tip 
treated successfully by nonoperative
•
Worland et al
• Distal to the prosthesis tip = closed
humerus fractures  nonoperative
treatment
• fractures located at the prosthesis tip
(type A and type B) ??
• did NOT heal with nonoperative
management.
– 5 cases in a series of 7 Boyd et al
– one case Bonutti et al
– 4 of 5 type B fractures  failed to heal, Kumar
et al
• fractures with loose prosthesis  longerstemmed implant
• 4 options:
– press-fitting proximally and distally
– cementing proximally and distally
– press-fitting proximally with cement distally
– cementing proximally with press-fitting distally
 Press-fitting
proximally and distally
– good quality of the humeral bone
– tight fit can be achieved
– obliquity fracture site
• cement proximally and distally:
– bone proximally is good to fair
– bone distally is good
– Transverse fracture
• press-fitting proximally and cement
distally:
– bone proximally is fair to poor
– bone distally is good
– fracture is rotationally stable
• shape / can be made
• small amount of osteolysis proximally:
– cement or bone graft
• extensive osteolysis proximally:
– bone graft is packed around the implant
within the cortical shell
• so extensive osteolysis:
– allograft prosthetic composite
• implant is secure and the joint is
reasonably mobile:
– approach the fracture site alone for fracture
fixation (plate with screws, pins and cerclage
cables)
• Allograft / Posterior iliac crest autograft
bone: nonunion -/+
• Fracture: transverse or nearly transverse
as rotational stability can be attained
through the use of the screws, pins and
cerclage  plate
• Fracture: oblique / implant stability, acute
 reduction of the fracture and cerclage
• Fracture: oblique / implant stability,
chronic  allograft + autograft
– 3/6 healed with nonoperative
– 1 failed nonoperative management
– 2 treated with immediate OP
• Type A fractures + loose humeral component
 OP: long-stem
• bone graft(allograft in acute cases and
posterior iliac crest autograft in cases with
delayed healing or nonunion)
• fixation with a cortical strut allograft or a
plate and screws/cables
• Type B fractures + good alignment / wellfixed humeral component: nonoperative
• However  nonoperatively  high fail
• not progressed toward union by 3 months
 OP
• Type B fracture + well-fixed humeral
component:
– plate / strut graft with screw fixation in the
distal portion and cerclage fixation in the
proximal portion + Bone graft
• Type B + loose humeral component 
cemented long-stem + posterior iliac crest
bone graft
• Type C fracture + well-fixed humeral
component: trial of nonoperative
– postoperative care:
• Within days after surgery: gently exercised with active
movement
• passive external rotation outward to neutral and in
elevation to 100°
• avoid stress at the fracture site
• continue with a passive program until healing
• long-stemmed implant + cemented: activeassisted motion program at 4 to 6 weeks
• Radial nerve injury
– careful dissection and exposure at the time of
fracture fixation
• swelling of the arm, forearm, and hand
– elevation, elastic support, and the gentle
active-motion program
• acute infection
• failure of humeral shaft healing
– 6 months, autograft/vascular bone graft
• well-aligned Type B fractures + well-fixed
humeral component: nonoperative
– High fail rate in Type B fractures
– 3 months
• humeral component fixed: open reduction
and internal fixation
• humeral component is loose: long stem
• Well-reduced Type C fractures: trial of
nonoperative treatment