INDICATIONS , TECNIQUES AND RESULTS FOR RSA ON FRACTURES

P . BAUDI

G . CAMPOCHIARO G . LEO

DEPARTMENT OF ORTHOPAEDICS AND TRAUMATOLOGY

UNIVERSITY OF MODENA AND REGGIO EMILIA CHIEF : PROF. F. CATANI

• FRACTURES OF PROXIMAL HUMERUS REPRESENT 6-10% OF ALL FRACTURES (BARON JA BONE 1996 )

• ARE THE THIRD MOST COMMON FRACTURE IN ELDERLY POPULATION AND IT HAS BEEN ESTIMATED THAT THE NUMBER OF THESE FRACTURES IN ELDERLY MAY TRIPLE BY THE YEAR 2030

THESE FRACTURES AFFECT AN INCRESING NUMBER OF ACTIVE PATIENTS WITH HIGH FUNCTIONAL DEMANDS

BETWEEN 60 AND 70 Y.O. ( COURT-BROWN CM INJURY 2006 )

• AROUND 80% of these fractures can be treated conservatively( HANSON B JSES 2009 )

BUT FOR COMPLEX , DISPLACED , HEAD SPLITTING FRACTURES, THERE IS NO CLEAR CONSENSUS REGARDING THE IDEAL

MANAGEMENT IN ELDERLY POPULATION AND IN ACTIVE POPULATION BETWEEN 65 Y.O. AND 75 Y.O.

• Since first Neer’s works , HEMIARTHROPLASTY ( HA) has becomethe gold standard in these situations

• LATER , MOST OF THE PUBBLISHED SERIES SHOVED RELIABLE RESULTS TO PAIN REDUCTION BUT DISAPPOINTING AND

UNPREDICTABLE FUNCTIONAL RESULTS

ROBINSON CM JBJS 2003

PADUA R MUSK SURG 2011 BOILEAU P 2000 SHOULD P. 2002

THE MAIN REASON OF BAD RESULTS IN HA CAN BE ATTRIBUTED TO

• TUBEROSITY FAILURE ( MALPOSITIONING , MIGRATION , NON –UNION , OSTEOLYSIS )

•

• TECHNICAL FAILURE OF RESTORATION OF HUMERAL LENGHT , VERSION , HUMERAL SIZE AND FINALLY ..

•

• TO LIMIT THE RISK OF TUBEROSITY FAILURE, MOST AUTHORS RECOMEMEND POST-OPERATIVE

IMMOBILIZATION FOR 4-6 WEEKS WITH THE HIGH RISK OF STIFNESS

TEN YEARS AGO THE REVERSE PROSTHESIS ( RSA ) WAS PROPOSED AS AN ALTERNATIVE PRIMARY PROCEDURE FOR COMPLEX PROXIMAL FRACTURES IN ELDERLY POPULATION OVER 75 Y.O. AND IN RECENT YEARS PUBLISHED SERIES HAVE SHOWN THE BENEFITS OF RSA

TERRAGNOLI F. J ORTHOP TRAUMAT 2007

GALLINET D ORTHOP TRAUM SURG RES 2009

VALENTI P ACTA ORTHOP BELG 2009

BOYLE MJ JSES 2012

• THE MOST IMPORTANT ASPECT IS THAT THE FUNCTIONAL OUTCOME AFTER RSA IS MORE

RELIABLE AND PREDICTABLE

• THE PATIENTS UNDERGOING RSA CAN’T EXPECT TO HAVE A ‘ NORMAL SHOULDER ‘ AGAIN BUT CAN EXPECT TO HAVE A PAINLESS AND FUNCTIONAL

SHOULDER IN MOST CASES WITH A MEAN ACTIVE ELEVATION OF 120° IN MOST SERIES AND WITH AN

ACTIVE INTERNAL AND EXTERNAL ROTATION

THIS RELIABILITY OF RESULTS IN RSA IS MOST EXPLAINED BY THE HIGH PERCENTAGE OF TUBEROSITY HEALING FROM 80% TO 100% WITH SPECIFIC REVERSE TRAUMA STEM

Y.O Gallinet(2008)

Young (2010)

Garrigues(2012)

HA74 ( 58-

84)75,5 69,3 (57-87)

RSA74 (49-

95)77.2 80,5 (67-97)

GALLINET 2008 16 HA VS 17 RSA ( TUBEROSITIES REMOVED ! ) 16 MONTHS GARRIGUES G 2012 9 HA VS 10 RSA ( TUBEROSITY REATTACHED ) 3.6 Y. F. U. YOUNG S. 2010 10 HA VS 10 RSA 44 & 22 MONTHS F.U.

THESE BETTER FUNCTIONAL RESULTS OF RSA FOR COMPLEX FRACTURES IN ELDERLY POPULATION WAS CONFIRMED IN SOME COMPARED CLINICAL

STUDIES ..

THE MEAN AGE WAS 75 Y.O. IN HA AND RSA GROUP , ONLY IN GARRIGUES ‘ S SERIES WE FOUND A SIGNIFICANT AGE

DIFERRENCE

PzFORWARDELEVATION

EXTERNAL ROTATION

Gallinet (2008) 17/16 53,5°/97,5° NO TUB 13,5°/9°

Young (2010) 10/10 108°/ 115° 48/49

Garrigues (2012) 9/10 91°/ 121° 31/34

SCORE Gallinet (2008)Constant

Young (2010)ASES

Garrigues (2012)ASES

HA 39 67 47,4

RSA 53 no tub. 65 81,1

THE RSA GROUP SHOVED BETTER FUNCTIONAL RESULTS AND BETTER SCORES IN ALL SERIES

WE HAVE A LOW DIFFERENCE IN ROM AND CONSTANT SCORE BETWEEN THE 2 GROUPS WHEN THE TUBEROSITIES WAS NOT

REATTACHED IN RSA

AIM OF OUR STUDY

PATIENTS AND METHOD FROM JANUARY ’08 TO APRIL ’12

64 PATIENTS UNDERWENT SHOULDER

REPLACEMENTFOR 3-4 PART COMPLEX FRACTURE OF PROXIMAL HUMERUS

• TO COMPARE MID-TERM RESULTS FOR RSA AND HA IN COMPLEX FRACTURES OF PROXIMAL HUMERUS

• TO COMPARE RESULTS IN 3 AGE RELATED GROUP WITH PARTICULAR ATTENTION TO THE GROUP FROM 65 Y.O. TO 75 Y.O.

HA : 35 RSA : 29

OF THESE 64 PATIENTS , 6 DIED AND 3 WERE LOST AT FOLLOW UP

5 HAWERE JUST OPERATED FOR PRHOSTETIC REVISION IN RSA AND

WERE NOT INCLUDED IN OUR STUDY

FRACTURE-DISLOCATION WITH AVULSION OF HUMERAL HEAD

HEAD SPLITTING OVER 40%

OUR INDICATION FOR HA OR RSA….

METHAPHISEAL ESTENSION-COMMINUTION

MEDIAL HINGE DISPLACED

COMPLEX FRACTURE WITH CUFF TEAR OR ARTHOPATY OR GLENOID FRACTURE ( INDICATION TO RSA )

RSA TECNIQUE

THE PATIENT WAS PLACED IN BEACH CHAIR POSITION , WHASED WITH CLOREXIDINE SOLUTION FOR PROPIONIUNBACTERI ACNEIS , COMPLETELY CLOSED WITH STERI-DRAPE

A STANDARD DELTO-PETTORAL APPROACH IS USED , THE CHEPALIC VEIN IS IDENTIFIED AND CLOSED PROXIMALY AND DISTALY , THE GREAT PETTORAL TENDON IS IDENTIFIED AND THE CLAVI-PETTORAL FASCIA IS RELEASED

THE ANTERIOR CIRCONFLEX ARTERY IS IDENTIFIED AND CLOSED , THE BICEPS TENDON IS RELEASED AND TUBEROSITIES ARE MOBILIZED WITH NON-ADSORBABLE STICHES PLACED IN SUBSCAPULARIS AND INFRASPINATUS –TERES MINOR TENDON . WE REMOVED THE SUPRASINATUS TENDON IF IS STILL PRESENT AND THE FRAGMENTS OF HUMERAL HEAD WERE REMOVED

THE GLENOID WAS EXPOSED WITH SPECIFIC SMALL RETRACTOR , THE LABRUM WAS REMOVED AND THE SUBSCAPULARIS TENDON WAS RELEASED FROM CAPSULAR TISSUE. WE IDENTIFIED THE BASE OF CORACOID PROCESS AND 6 O’CLOCK OF THE GLENA , WE DRAWN WITH ELECTROSURGERY TOOL , 2 LINES FROM 12 O’CLOCK TO 6 O’CLOCK AND FROM 3 O’CLOCK TO 9 O’ CLOCK . THE CENTRAL DRILL HOLE WAS PLACED AT INTERSECTION OF THESE 2 LINES

NEXT , WE REAMED THE GLENOID WITH AN ANGLE BETWEEN 0° TO 10° INFERIOR , THE BASEPLATE WAS IMPACTED INTO GLENOID AND 2 SCREWS WERE PLACED IN APPROPRIATE POSITION BEFORE INSERTION OF GLENOSPHERE

« THE BASEPLATE AS LOW AS POSSIBLE , THE PRHOSTESIS AS HIGH AS POSSIBLE «

• THE HUMERAL MEDULLARY CANAL WAS REAMED TO APPROPRIATE SIZE

• IN PATIENT WITH OSTEOPOROTIC BONE WE USE CEMENTED STEM ( 57 %)

• IN ALL PATIENTS WE USED SPECIFIC TRAUMA STEM FOR RECONSTRUCTION OF TUBEROSITY

• THE DEPTH OF PLACEMENT WAS EXTIMATED WITH THE SUPERIOR BORDER OF PECTORALIS MAJOR AND THE RECONSTRUCTION OF GREAT TUBEROSITY

• WE PLACED THE HUMERAL PROSTHESES IN 10° OF RETROVERSION BASED ON EPICONDYLAR AXIS

IN 18 RSA WE USED S-R GLENOID AND 36 MM OF GLENOSPHERE ( IN 5 CASES ECCENTRIC ) IN 5 RSA WE USED S GLENOID AND 40 MM OF GLENOSPHERE IN 22 CASES WE USED 2 SCREWS AND IN 1 CASE 1 SUPERIOR SCREW

FINALLY , WE PERFORMED A STABLE RECONSTRUCTION OF THE TUBEROSITIES USING 4 DRILL HOLES IN LATERAL CORTEX OF THE HUMERUS WITH NON –ABSORBABLE SUTURES ,THE HOLE PRESENT ON HUMERAL REVERSE STEM AND THE SUTURES PASSED TROUGH CUFF TENDON , LIKE DESCRIBED BY BOILEAU THE STABILTY OF IMPLANT WAS TESTED IN ADDUCCTION , ABDUCTION AND COMBINED INTRA AND EXTERNAL ROTATION

N. PAT.

Y.O.(min-max)

F.U.MONTHS

(min-max)

HA 27 70 (55-

85)30 (15-57)

RSA 23 75 (65-

85)33 (15-64)

THE PATIENTS WERE OFTEN WOMEN 42 VS 8 MAN 1 BILATERAL

50 PATIENTS WERE REVIEWED

• IN ALL PATIENTS WE USED SPECIFIC TRAUMA STEM ( LIMA SMR AND ZIMMER ) EVEN FOR HA AND RSA GROUP

• THE SURGICAL TREATMENT WAS PERFORMED AT A MEAN OF 6 DAYS IN BOTH GROUP

• NO DIFFERECENCE IN TYPE OF FRACTURE AND IN % OF OSTEOPOROTIC BONE ( 40%) AND DOMINANT SIDE

• WE HAVE A DIFFERRENCE IN POST OPERATIVE IMMOBILATION : 25 DAYS MEAN IN HA GROUP , 14 DAYS MEAN IN RSA GROUP

N°pzOsteoporotic

bone Dominant side

ImmobilationDays P.O.

HA 27 (41%) (63%) 25 (15-40)#

RSA 23 (41%) (59%) 14 (10-15)#

IN ALL PATIENTS WE PERFORMED

RX + CT SCAN WITH MPR RECONSTRUCTION AND 3D RECONSTRUCTION

TO EVALUATE • BONE QUALITY • FRACTURE PATTERN

CUFF LESION PARTIAL SOPRASPINATUS MASSIVE

HA 5 (22%) 5 0 0

RSA 16 (70%) 2 4 10

THE PRESENCE OF ROTATOR CUFF TEARS WAS PRE-OPERATIVELY DETECTED WITH ANAMNESTIC INVESTIGATION AND SAGITTAL CT SCAN

FOR MUSCLES IPO-ATRHOPY AND INTRA-OPERATIVELY CONFIRMED

WE HAVE 70 % OF CUFF LESION IN RSA GROUP

RESULTS

ALL PATIENTS WERE REVIEWED BY AN INDEPENDENT OBSERVER .

ALL PATIENTS UNDERWENT CLINICAL EXAMINATION ( ROM ) , DASH SCORE,CONSTANT MODIFIED SCORE, ASES SCORE.

STRENGHT WAS MEASURED WITH ISOKINETIC DYNAMOMETERAND STRENGHT RATIO WAS CALCULATED WITH CONTROLATERAL HEALTHY SIDE.

ALL PATIENTS UNDERWENT STANDARD X-RAY EXAMINATION INCLUDING A.P. VIEW IN THREE ROTATIONS AND AN AXILLARY VIEW

ROM N°

FORWARD

ELEVATIO

N MEAN

±SD

ABDUTION

MEAN ±SD

R1

MEAN ±SD

R2

MEAN ±SD

INTERNAL

ROTATION

MEAN ±SD

HA 27 95 ±44# 88 ±40# 25 ±15 49 ±19§ 3 ±1

RSA 23 129 ±36# 126 ±36# 17 ±11 50 ±23° 3,3±2

PzFORWARDELEVATION

EXTERNAL ROTATION

Gallinet (2008) 17/16 53,5°/97,5° 13,5°/9°

Young (2010) 10/10 108°/ 115° 48/49

Garrigues (2012) 9/10 91°/ 121° 31/34

THE RSA GROUP HAD A SIGNIFICANTLY GREATER FORWARD ELEVATION AND ABDUTION THAN HA GROUP . THERE IS NO SIGNIFICANT DIFFERENCE IN INTERNAL ROTATION AND IN

EXTERNAL ROTATION IN R2 POSITION , SLIGHTLY DIFFERENCE IN EXTERNAL ROTATION IN R1 POSITION

GROUP

55-64 Y.O.PATIENTS

Constant

mean ±SD

Constant

modified mean

±SD

DASH mean

±SD

p-Ases mean

±SD

HA 10 50 ±19 62 ±20 27 ±29 66 ±27

We have decide to divide the patients in 3 grouprelated to the age : the purpose is understand the

difference in the group between 65 y.o. and 75 y.o. where the decision making is more difficult

IN AGE RELATED GROUP FROM 55 Y.O. TO 65 Y.O WE HAVE ONLY HA AND WE HAVE A MEAN

MODIFIED CONSTANT OF 62 POINTS

GROUP

65-74 Y.OPATIENTS

Constant

mean ±SD

Constant

modified

mean ±SD

DASH mean

±SD

p-Ases

mean ±SD

HA 12 38 ±12# 53 ± 15# 37 ±10 59 ±20

RSA 10 62 ±16# 90 ±24# 26 ±18 76 ±14

.. BUT EVEN IN GROUP FROM 65 Y.O. TO 75 Y.O. THE COSTANT SCORE , DASH SCORE AND ASES SCORE WAS SIGNIFICANTLY

BETTER IN RSA GROUP

GROUP

75-85 Y.O.PATIENTS

Constant

mean ±SD

Constant

modified

mean ±SD

DASH

mean ±SD

p-Ases mean

±SD

HA 5 39 ±18# 58 ±27# 45 ±23 48 ±24#

RSA 13 56 ±12# 83 ±20# 31 ±21 72 ±16#

THE DIFFERENCE BETWEEN HA AND RSA GROUP IN COSTANT SCORE , DASH AND ASES SCORE WERE AMPLIFIED IN OLDER GROUP OVER 75 Y. O

0

50

100

150

Globale Età 55-64 Età 65-74 Età 75-85

95118

88 83

129 137124

FORWARD ELEVATION

IF WE ANALYZE ROM IN THREE AGE RELATED GROUP , WE CAN OBSERVE THE SAME SIGNIFICANTLY BETTER RESULTS IN RSA GROUP 65 Y.O. -75 Y.O.

ABDUCTION 0

50

100

150

Globale Età 55-64 Età 65-74 Età 75-85

88106

76 80

126139

118

THE SAME RESULT FOR ABDUCTION

0

10

20

30

40

Globale Età 55-64 Età 65-74 Età 75-85

25

32

16

24

17 19 16

EXTERNAL ROTATION

ONLY IN EXTERNAL ROTATION IN R1 WE AVE BETTER RESULTS IN ALL

AGE RELATED HA GROUP !

0

3

6

Globale Età 55-64 Età 65-74 Età 75-85

3 2.8 2.53.53.3 3.5 3.1

INTERNAL ROTATION

WE HAVE NOT SIGNIFICANT DIFFERENCE IN INTERNAL ROTATION

0%

100%

ABD R1 R2

0.4 0.56 0.45

1.03 0.86 0.72

Endoprotesi Protesi inverse

STRENGHT RATIO ( TO CONTRALATERAL HEALTY SIDE ) WAS BETTER IN RSA GROUP .IN ABDUTION THE STRENGHT RECOVERY WAS 40% IN HA GROUP AND 103 % IN RSA GROUP ;IN EXTERNAL ROTATION ( R1 AND R2 POSITION ) THE STRENGHT RECOVERY WAS 56% - 45% IN HA GROUP AND 86% - 72% IN RSA GROUP

X-RAY EXAMINATION

TUBEROSITYCONSOLIDATION HA RSA

YES

11 19

83%40%

AT X- RAY EXAMINATION , TUBEROSITY CONSOLIDATION WAS JUDGED GOOD IN 40% PATIENTS IN HA GROUP AND

IN 83% PATIENTS IN RSA GROUP

RSA

THE HIGH PERCENTAGE OF TUBEROSITY HEALING FROM 80% TO 100% WITH SPECIFIC RSA TRAUMA STEM CAN BE OBTEINED FOR

2 REASONS

• WITH THE RESECTION OF SOPRASPINATUS AND THE MEDIALIZATION OF THE CENTER OF ROTATION IN RSA , THERE IS

LESS TENSION ON THE ROTATOR CUFF AND LESS FORCES ON TUBEROSITIES ( THIS CAN PREVENT PROXIMAL MIGRATION OF

THE TUBEROSITIES )

• THE BIOMECHANICS OF RSA RESULTS IN THE DELTOID FORCES APPLIED DIRECTLY TO THE GLENOSPHERE DURING ELEVATION

WITH A DECREASE OF THE TORQUE ON TUBEROSITIES

IN CASE OF TUBEROSITY RESORPTION IN RSA , WE HAVE HOVEWER A PAINLESS AND FUNCTIONAL SHOULDER

WITH THE SAME SITUATION IN HA , WE HAVE FUNCTIONAL DISASTER WITH A SHOULDER NOT USEFUL FOR DAILY ACTIVITY

COMPLICATION OF RSA GROUP

• 3 CASES OF G.N. GRADE 1• 4 CASES OF RESORPTION OR MALCONSOLIDATION OF TUB .• 1 CASE OF EARLY INSTABILITY IN POST- OPERATIVE

SPATIOTEMPORAL DISORIENTATION AND AGITATION• NO INFECTION NO LOOSENING NO REVISION

WEAKNESS OF OUR STUDY RETROSPECTIVE STUDY , NO LONGER F.U

STRENGHT OF OUR STUDY TOTAL NUMBER OF PATIENTS AND CLINICAL RESULTS IN 3

GROUP OF AGE

22 PATIENTS FROM 65 Y.O. TO 75 Y.O.

CONCLUSION

IN PATIENTS UNDER 65 Y.O. AFFECTED BY A PROXIMAL HUMERAL COMPLEX FRACTURE , OPEN AND STABLE REDUCTION IS THE FIRST CHOICE , IF THIS SOLUTION IS NOT POSSIBLE , WE PERFORMED A HA WITH SPECIFIC TRAUMA STEM , AUTOLOGOUS BONE AROUND PROXIMAL STEM AND STABLE FIXATION OF TUBEROSITY

IN PATIENTS OVER 75 Y.O IF THE CONSERVATIVE TREATMENT WAS NOT POSSIBLE , WE PERFORMED A RSA WITH A STABLE RECONSTRUCTION OF TUBEROSITY AND AN EARLY REHABILITATION PAY ATTENTION TO A MEDICAL GENERAL CONDITION AND SPATIOTEMPORAL DISORIENTATION – AGITATION

IN PATIENTS BETWEEN 65 Y.O. AND 75 Y.O. WITH A COMPLEX FRACTURE WE CONSIDERED RSA THE PRIMARY SOLUTION IN ALL CASES OF

• OSTEOPOROTIC BONE

• MORE FRAGMENTS OF G.T.

• IN PRESENCE OF CUFF TEAR , GLENOID FRACTURE , AND GLENO-HUMERAL ARTHROPATY

IN OTHER CASES WE DISCUSS WITH THE PATIENT THE HA OR RSA SOLUTION AND RESULTS .. AND AT THE END OF MY TALKING , I SAY …

‘ I WANT FOR YOU A SUCCESSFUL RESULT THE FIRST TIME , BECAUSE A FAILED PRHOSTHESIS IS VERY DIFFICULT TO TREAT AND THE RESULTS

OF A REVISION IS LOWER THAN A PRIMARY RSA ‘

REVISION OF HA SEPTIC MOBILIZATION