Abstract
Objective
Achieve stable fixation to initially start full range of motion (ROM) and to prevent secondary displacement in unstable fracture patterns and/or weak and osteoporotic bone.
Indications
(Secondarily) displaced proximal humerus fractures (PHF) with an unstable medial hinge and substantial bony deficiency, weak/osteoporotic bone, pre-existing psychiatric illnesses or patient incompliance to obey instructions.
Contraindications
Open/contaminated fractures, systemic immunodeficiency, prior graft-versus-host reaction.
Surgical technique
Deltopectoral approach. Identification of the rotator cuff. Disimpaction and reduction of the fracture, preparation of the situs. Graft preparation. Allografting. Fracture closure. Plate attachment. Definitive plate fixation. Radiological documentation. Postoperative shoulder fixation (sling).
Postoperative management
Cryotherapy, anti-inflammatory medication on demand. Shoulder sling for comfort. Full active physical therapy as tolerated without pain. Postoperative radiographs (anteroposterior, outlet, and axial [as tolerated] views) and clinical follow-up after 6 weeks and 3, 6, and 12 months.
Results
Bony union and allograft incorporation in 9 of 10 noncompliant, high-risk patients (median age 63 years) after a mean follow-up of 28.5 months. The median Constant–Murley Score was 72.0 (range 45–86). Compared to the uninjured contralateral side, flexion was impaired by 13 %, abduction by 14 %, and external rotation by 15 %. Mean correction of the initial varus displacement was 38° (51° preoperatively to 13° postoperatively).
Zusammenfassung
Operationsziel
Erreichen einer stabilen Osteosynthese bei instabilen Frakturen und/oder schwacher/osteoporotischer Knochenstruktur, um von Beginn an eine volle Bewegungsstabilität (ROM) zu erreichen.
Indikationen
(Sekundär) dislozierte proximale Humerusfrakturen (PHF) mit instabiler medialer Abstützung und substanziellem Substanzdefekt. Schwache/osteoporotische Knochenstruktur. Bestehende Psychosen oder Patienten-Non-Compliance, Instruktionen zu befolgen.
Kontraindikationen
Offene/kontaminierte Frakturen. Systemische Immundefekte. Stattgehabte Abstoßungsreaktion.
Operationstechnik
Deltoideopektoraler Zugang. Identifikation der Rotatorenmanschette. Reposition der Fraktur, Präparation von Situs und Allograft. „Allografting“. Verschluss der Fraktur. Anpassung der Platte. Definitive Fixierung der Platte. Radiologische Dokumentation. Postoperative Fixierung der Schulter im Gurt.
Weiterbehandlung
Kryotherapie. Analgetische Medikation und Schultergurt nach Bedarf. Volle aktive Physiotherapie soweit möglich nach Schmerzvorgabe. Postoperative Röntgenaufnahmen (anteroposterior, outlet view und axial [je nach Patiententoleranz]) und klinisches Follow-up nach 6 Wochen sowie nach 3, 6 und 12 Monaten.
Ergebnisse
Knöcherne Heilung und Einheilung des Allografts bei 9 von 10 nicht compliant Hochrisikopatienten (medianes Alter 63 Jahre) bei einem mittleren Nachuntersuchungszeitraum von 28,5 Monaten. Der mediane Constant-Murley-Score war 72,0 (Spanne 45–86). Verglichen zur unverletzten kontralateralen Seite konnte eine Verbesserung der Flexion von 13 %, der Abduktion von 14 % und der Außenrotation von 15 % gefunden werden. Die mittlere Korrektur der initialen Varusfehlstellung war 38° (51° präoperativ vs. 13° postoperativ).
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Introduction
This technique may reinforce and augment internal plate fixation in displaced proximal humeral factures (PHF) with an unstable medial hinge, especially in weak and osteoporotic bone with substantial loss of the structural bony scaffold. Compared to conventional plate fixation methods, it may not only decisively increase bony stability and prevent secondary fracture displacement, but also allow for full initial range of motion (ROM) [1].
Surgical principles and objective
To augment surgical fixation and to achieve postoperative stability strong enough to initially start full ROM and to prevent secondary displacement in unstable fracture patterns and/or weak and osteoporotic bone.
Advantages
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Joint preserving method without artificial material
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Increased stability after open reduction and internal plate fixation of PHF
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Anatomic reduction in cases of substantial bone loss using a biological structural void filler
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Strong structural bony congruency
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No additional surgical approach, wound site, or donor morbidity
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Average technical skills demanded
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Initial full weightbearing and ROM
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Potential prevention of secondary postoperative fracture displacement
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Very low infection rates or graft-versus-host reactions [1, 3]
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Solid bone stock for potential secondary prosthetic interventions
Disadvantages
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Allogenic bony material
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Potential risk of infection, transmission of diseases and graft-versus-host reaction
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Minimal risk of nonunion
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Minimally increased operation time
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Limited accessibility to allografts
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Increased costs if not derived by in-house bony banks
Indications
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(Secondarily) displaced 2‑part proximal humerus fractures (PHF) with an unstable medial hinge and substantial bony deficiency
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Cases of weak and osteoporotic bony structure
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Increased risk for secondary displacement due to pre-existing psychiatric illnesses or patient incompliance to obey rules [2, 5]
Contraindications
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Open or contaminated fractures
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Systemic immunodeficiency
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Running systemic chemotherapy
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Prior graft-versus-host reaction
Patient information
The following risks are possible:
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Contamination/transmission of diseases [3]
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Graft-versus-host reaction, systemic host rejection
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Implant failure (screw perforation, loosening, breakage, or intolerance)
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Nonunion
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Bony dissolution over time
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Disintegration and secondary displacement
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Re-operation
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Infection, thrombosis, embolism, vascular or nerve damage
Preoperative work up
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Bilateral shoulder CT and 3D reconstruction to distinctively assess the grade of displacement and/or the size of the bony defect
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Pre-order (in-house bank or third party) of an appropriately sized bony allograft (at least one half of a femoral head)
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Femoral heads seem to be rather nonosteoporotic if derived from a replacement surgery of an arthritic hip
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The allograft should be fresh frozen and test negatively for transmittal diseases, contamination, and infection, no antibiotic treatment or preserving processing to the graft prior to implantation
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Thawing of the fresh frozen graft to room temperature at least 1 h prior to surgery
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Shaving of the complete shoulder region, including axilla
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Single shot intravenous antibiotic administration (bone consistently, at least 30 min prior to the skin cut, i. e., aminopenicillin) [4]
Instruments
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Bone saw to decorticate the allograft
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Luer-like instruments (Rangeur)
Anesthesia and positioning
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General anesthesia
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Interscalene block (beneficial and recommended, but not mandatory)
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Supine position and mild angulation of the upper body (approximately 20°; Fig. 1)
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Positioning on the edge of the table with the arm freely movable on an optional adjustable table (Fig. 2)
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Regular prepping and wrapping
Postoperative management
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Removal of stitches after 12–14 days
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Cryotherapy as needed during inpatient care
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Anti-inflammatory medication on demand
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Shoulder sling for comfort
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Active assisted to active full ROM, as tolerated
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Inpatient postoperative anteroposterior (ap), outlet view (ov), and Velpeau view radiographs
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Clinical and radiological follow-ups (FU):
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Week 6: clinical FU, ap, ov, and ax (as tolerated) radiographs
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Months 3, 6, and 12: clinical FU, ap, ov, and ax radiographs
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Errors, hazards, complications
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Allograft cut too small: use of the cut parts as additional bony putty around the graft to achieve a press fitting construct prior to definitive fixation
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Infection of the allograft: indication for surgery and explantation of the graft; implantation of a spacer, several surgical re-looks as needed, and priming for the definitive procedure (i. e., implantation of an antibiotic loaded allograft; prosthesis)
Results
Methods
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Retrospective case series between July 2009 and November 2011 (Tab. 1; [1])
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Cancellous allograft was used to augment plate fixation of the fractures
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Inclusion criteria
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1.
Varus displaced two-part fracture (AO A2.2; >45°, unstable eroding subsidence, impression of the shaft into the head)
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2.
Interval between injury and surgery between 1 and 8 weeks following an initial trial of conservative treatment
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3.
Implantation of a structural bony allograft
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4.
High-risk patient
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5.
Patient noncompliance
-
1.
Outcomes
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Median follow-up 28.5 months (Tab. 2)
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Nine of 10 fractures healed with incorporation of the bony allografts
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No systemic or local complications
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No significant loss of reduction or evidence of avascular necrosis of the humeral head
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Median Constant–Murley score 72.0 (range 45–86)
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Median pain on the visual analog scale 1 (range 0–7)
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Median ROM:
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Flexion 155° (range 90–170°), abduction 168° (range 95–180°), external rotation 43° (range 30–50°)
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Flexion −13 %, abduction −14 %, external rotation −15 %, compared to the uninjured contralateral side
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Median abduction power 64 % of the uninjured side
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Median varus displacement 51° (range 45–59°) preoperatively, 4° (range −5 to 19°) intraoperatively, 13° (range 1–18°) at the time of the final follow-up
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Improvement of 38°
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References
Euler SA et al (2015) Allogenic Bone Grafting for Augmentation in Two-Part Proximal Humeral Fracture Fixation. Arch Orthop Trauma Surg 135(1):79–87
Mathog RH et al (2000) Nonunion of the mandible: an analysis of contributing factors. J Oral Maxillofac Surg 58(7):746–752
No authors listed (2008) US Census Bureau. Statistical abstract of the United States 2008, no. 181: Organ Transplants and Grafts, 1990 to 2005. Washington, DC
Paul-Ehrlich-Gesellschaft für Chemotherapie e. V. (2010) Perioperative Antibiotika-Prophylaxe. Empfehlung einer Expertenkomission. Chemother J 19:70–84
Serena-Gomez E, Passeri LA (2008) Complications of mandible fractures related to substance abuse. J Oral Maxillofac Surg 66(10):2028–2034
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Conflict of interest
S. A. Euler, F.S. Kralinger, C. Hengg, M. Wambacher, and M. Blauth state that there are no conflicts of interest.
Study number 5105 approved by the ethics committee of the Medical University of Innsbruck on 16 May 2013.
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Editor
A.B. Imhoff, Munich
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J. Kühn, Mannheim
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Euler, S.A., Kralinger, F.S., Hengg, C. et al. Allograft augmentation in proximal humerus fractures. Oper Orthop Traumatol 28, 153–163 (2016). https://doi.org/10.1007/s00064-016-0446-8
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DOI: https://doi.org/10.1007/s00064-016-0446-8