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tisdag 25 april 2023

Olkapäänluun tyvimurtumien (PHF) korjaustekniikoista aiempia ja viimeaikaisimpia

 https://orthopaedia.com/media/2019/9/f64b8558-fb5d-47cc-aca4-5b82b1cda4cc-1568403762325.png

Figure 1: The four osseous segments are humeral head and articular surface (1), greater tuberosity (2), lesser tuberosity (3) and humeral shaft (4). The so-called anatomic neck is shown in green; this represents the fused epiphyseal plate below the articular surface. The so-called surgical neck is shown in blue. This is the junction between the shaft and the tuberosities. The bicipital groove lies between the greater and lesser tuberosities.

 

 Olkaluu = HUMERUS 

1. Olkaluun pää . CAPUT Humeri on pallomaiseksi paksuuntunut. . Olkaluun pään alla oleva  matala kuroutuma (vihreä viiva) on anatominen olkaluunkaula  Collum anatomicum. Se vastaa  fuusioitunutta epifyysilevyä  CAPUT-nivelpinnan alla. ( Heti maintun kuroutuman alapuollela on kaksi kyhmyä, iso ja pieni olkakyhmy).

2.Tuberculum majus,  Iso olkakyhmy. Se suuntautuu sivulle ulospäin.

3.Tuberculum minus, Pieni olkakyhmy. se suuntautuu eteenpäin. 

Kumpikin kyhmy jatkuu alaspäin pitkänä olkalluun vartta myöten kulkevana särmänä (särmä = CRISTA):  )ison ja pienen olkakyhmyn särmä = CRISTA tuberculi majoris ja minoris).  Niiden välissä on kyhmyjen välinen vako (vako= SULCUS): SULCUS  intertubercularis. Vako erottaa kyhmyt toisistaan. tässä vaossa kulkee Hauislihaksen pitkän pään  jänne.

4. Olkaluun varsi (Corpus humeri) 

 https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2019/06/f006-001b-9780323297318.jpg?w=960

 

 

  • GRACITELLI MEC, LOBO FL, FERREIRA GMA, DA PALMA MV, MALAVOLTA EA, BENEGAS E et al. outcomes evaluation of locking plate osteosynthesis in displaced fractures of the proximal hiumerus. Rev Bras Ortop Engl Ed. 2013 Nov; 48(6): 491-9. DOI: 10.1016/j.rboe.2013.12.014 

 Objective:To evaluate functional outcomes, radiographic findings and complications of proximal humeral fractures treated with locking plates and to determine prognostic factors for successful clinical outcomes. Methods: Forty patients undergoing internal fixation of fractures of the proximal humerus with the Philos® plate were included in the study. The surgeries were performed between 2004 and 2011 and the patients underwent radiographic and clinical evaluation, by Constant–Murley and Dash score. Outcomes were analyzed by use of multivariate regression with several different variables.

 

  • CHEN H, Ji X, GAO Y, ZHANG L, ZHANG Q,,LIANG X et al.  Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemi-arthroplasty for repari of osteoporotic four-part proximal humerus fracture: Consecutive, prospective, controlled and comparative study. Orthop Traumatol Surg Res. 2016 May: 102(3):287-92. DOI: 10.1016/j.otsr.2015.12.021  

 Objectives: To compare the outcomes of intramedullary fibular allograft (IFA) with locking compression plates (LCPs) versus shoulder hemi-arthroplasty (HA) in osteoporotic four-part proximal humeral fracture (PHF). Methods: Between January 2010 and December 2012, totally 60 cases with osteoporotic four-part PHF were enrolled in this study and were randomly separated into IFA and LCPs group and HA group (n=30). Additionally, surgery indexes for patients in the two groups, such as Constant-Murley score (CMS), the Disability of Arm, Shoulder and Hand (DASH) score, individual subject evaluation of the outcomes, plain X-ray, and computer tomography (CT) scanning were evaluated and compared. 

 https://i0.wp.com/musculoskeletalkey.com/wp-content/uploads/2019/06/f006-001b-9780323297318.jpg?w=960

  • MAYER D, JAEGER M, IZADPANAH K, STROHM PC, SUEDKAMP NP. Proximal Humeral Fractures (PHF) Treatment in Adults: J Bone Jt Surg. 2014 Feb;96(3):251-61.  DOI:10.2106/JBJS.L.01293 

Abstract: Most proximal humeral fractures (PHF) affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis   .Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment. 

ROTATOR CUFF= Kiertäjäkalvosin   https://fi.wikipedia.org/wiki/Kiert%C3%A4j%C3%A4kalvosin

rotator cuff; olkanivelen nivelpussin yläosa, jota vahvistavat ylemmän ja alemman lapalihaksen, lavanaluslihaksen ja pienen liereälihaksen jänteet 
 
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Introduction: The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA)  and hemiarthroplasty for the treatment of proximal humerus fractures(PHF). Methods:  A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018. Results:  One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications.
 Discussion:  There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants. Proximal humerus fractures account for approximately 5% of all fractures and are the third most common fracture type in those older than 65 years.1,2 
 Management options are influenced by a number of factors, among which are fracture type and severity, patient age and comorbidities, patient's functional status, and surgeon experience.3,4 
A number of treatment options exist, ranging from short-term immobilization with early range of motion and physical therapy to surgical management.1 
Most proximal humerus fractures in the elderly population can be managed nonsurgically and with good functional outcomes.3,5

Given the difficulty in closed management of displaced three-part and four-part proximal humerus fractures, as well as the associated high risk of osteonecrosis, shoulder hemiarthroplasty has long been used for complex fracture types.6 

Along with the advent of reverse total shoulder arthroplasty, both hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RSA) have become surgical treatment options for proximal humerus fractures in the elderly patient population.

Recent epidemiologic data suggest that the use of RSA has become more prevalent, up by 406% over an 8-year span from 2005 to 2012 in the Medicare population, compared with a 47% decreased use of HA over the same period.7 

 Both patient factors and surgeon preference have been cited for the shift in implant utility.8,9

With good clinical outcomes, improved shoulder rotation, and relatively shorter surgical times, HA remains a viable option in the surgical management of complex, comminuted (pulveroitunut)  proximal humerus fractures.10,11 Outcomes after HA, however, correlate closely with anatomic healing of the tuberosities, with malposition leading to markedly worse functional outcomes and decreased shoulder range of motion.3,10–12 Because anatomic tuberosity healing is essential for restoration of rotator cuff function, the use of RSA for complex proximal humerus fractures can arguably mitigate the necessity of relying on anatomic tuberosity fixation.3,13 This factor, along with predictably good early and midterm clinical outcomes, makes RSA a particularly useful surgical option in elderly patients with complex proximal humerus fractures, particularly those with osteopenic   bone.14,15 The purpose of this study was to evaluate the 30-day postoperative complication rate and associated risk factors in the early postoperative period after the surgical treatment of proximal humerus fractures with reverse total shoulder arthroplasty compared with hemiarthroplasty.

Author Information
Clinical Orthopaedics and Related Research 481(4):p 735-747, April 2023. | DOI: 10.1097/CORR.0000000000002480 Abstract  Background  Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear. Questions/purposes:  (1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?'
 
 
 
 
 Management of Proximal Humerus Fractures in Adults-A Scoping ReviewBaker HP, Gutbrod J, Strelzow JA, Maassen NH, Shi L. J Clin Med. 2022 Oct 18;11(20):6140. doi: 10.3390/jcm11206140. PMID: 36294459 Free PMC article. Review.DOI: 10.3390/jcm11206140 
  • Abstract
    Proximal humerus fractures (PHF)  are the third most common fracture type in adults, with their incidence increasing over time. There are varied approaches to both the classification and treatment of proximal humerus fractures. Optimal treatments for this fracture type are still widely open to debate. This review summarizes the current and historical treatment modalities for proximal humerus fractures. In this paper, we provide updates on the advances and trends in the epidemiology, classification, and operative and nonoperative treatments of proximal humerus fractures.Keywords: fracture; management; proximal humerus; shoulder arthroplasty.
     
     
     
  • The Evolution of Reverse Total Shoulder Arthroplasty and Its Current Use in the Treatment of Proximal Humerus Fractures in the Older Population.
    Larose G, Virk MS. J Clin Med. 2022 Sep 30;11(19):5832. doi: 10.3390/jcm11195832. PMID: 36233699 Free PMC article. Review.
    Abstract
    Proximal humerus fracture (PHF) is a common injury in the older population. While the majority of these fractures are treated non-operatively, a small subset of patients may benefit from surgical treatment. However, there continues to be an ongoing debate regarding the indications and ideal surgical treatment strategy. The use of reverse total shoulder arthroplasty (RTSA) has resulted in a paradigm shift in the treatment of PHFs in the older population. Unique biomechanical principles and design features of RTSA make it a suitable treatment option for PHFs in the older population. RTSA has distinct advantages over hemiarthroplasty and internal fixation and provides good pain relief and a reliable and reproducible improvement in functional outcomes. As a result, there has been an exponential increase in the volume of RTSA in the older population in last decade. The aim of this paper is to review the current concepts, outcomes and controversies regarding the use of RTSA for the treatment of PHFs in the older population.

    Keywords: fragility fractures; hemiarthroplasty; internal fixation; proximal humerus fractures; reverse total shoulder arthroplasty.

 

 

 

 


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