61.1 Goals of Procedure

The goal of this procedure is to anatomically restore the proximal humerus, creating a stable enough construct to allow early mobilization and ultimately a return to full function.

61.2 Advantages

Proximal humerus fractures (PHFs) typically occur in patients older than 60 years, often with poor bone quality. ¹

The development of locking plate and angle stable technology counterbalance the effect of poor bone quality on fixation stability, minimizing fixation failure. ² However, poor outcomes and postoperative complications are relatively common due to poor bone stock in the humeral head. The central portion of the humeral head is often a hollow shell of subchondral bone. Furthermore, the metaphysis is also often devoid of bony trabeculae. To circumvent poor biomechanical fixation due to compromised bone stock, we have successfully used intramedullary augmentation and inferomedial support of the calcar by placing an endosteal fibular allograft. This technique has clearly demonstrated better maintenance of reduction during healing. ^{2 – 4} Anatomic restoration of the fracture fragments helps ensure the correct position of the rotator cuff musculature. During the described surgical technique, tenodesis of the long head of the biceps is performed to facilitate fracture reduction, and likely decreases associated symptoms.

61.3 Indications

Indications include unacceptable displacement of the fracture fragments, or fracture patterns too unstable to allow early range of motion. The characteristics of the fracture (i.e., displacement and angulation of the parts more than 1 cm or more than 45 degrees) and the patient are the most important decisive factors on whether to operate or not operate.

61.4 Contraindications

Patients who are unfit for anesthesia or unable to engage in postoperative rehabilitation protocols are contraindicated for this procedure. The experience has been that these patients due to either physical or mental illness do not receive sufficient benefit from operative treatment.

Other contraindications are the following:

• 
  

  An unreconstructable humeral head (significant head split, or multiple articular fragments).

  
  
• 
  

  A devascularized humeral head (no soft-tissue attachment to the articular segment, calcar length less than 8 mm, and disruption of the medial hinge).

61.5 Preoperative Preparation/Positioning

Plain radiographs (including an anteroposterior [AP], scapular Y, and axillary views) and a 3D CT scan should be obtained for each patient prior to surgical intervention and used for planning ( Fig. 61.1a–c). The condition of the calcar, bone quality, and displacement pattern should be noted. MRI may be useful when rotator cuff tears and labral lesions are suspected. ^{2 , 7 – 9}

The patient is placed in the sloppy lateral position on a radiolucent table, in which patients are angled 30 to 40 degrees above the lateral with assistance of a beanbag ( Fig. 61.2 ). With the patient in this position, the surgeon has access to the anterior, posterior, and the lateral aspects of the proximal humerus. It also presents the anterolateral aspect of the shoulder directly to the surgeon. The image intensifier (C arm) is placed on the opposite side of the table and draped into the sterile field. With the C arm rotating between 45 degrees rollback and 45 degrees rollover views, orthogonal fluoroscopic images and scapular Y views are easily obtained with little movement of the arm. Prior to draping the patient, the ability to obtain all intraoperative views with the C arm is checked. We do not use an arm holder.

61.6 Operative Technique

Using the extensile anterolateral approach ( Fig. 61.3 ), an incision is made between the anterior and middle heads of the deltoid, beginning at the anterolateral corner of the acromion and extending distally enough toward the lateral epicondyle of the humerus. The raphe between the anterior and middle head of the deltoid muscle is identified and carefully opened bluntly in line with the deltoid fibers to obtain an avascular approach ( Fig. 61.4a, b). ¹⁴ The axillary nerve is identified approximately 6.5 cm distally to the acromion and 3.5 cm from the greater tuberosity ( Fig. 61.4c, d). ^{2 , 8 , 14 , 15} Neurolysis is performed to mobilize and protect the nerve through the procedure. In order to gain further exposure, without disrupting the soft tissue, the rotator cuff is put into view by incising the subacromial bursa. Nonabsorbable traction sutures are placed into the three heads of the rotator cuff: subscapularis tendon, supraspinatus tendon, and infraspinatus tendon. ¹⁶ Care is taken to identify the rolled edge of the subscapularis so sutures are not placed in the rotator interval that may limit motion.

The bicipital groove is exposed and the oblique fascicle is released to expose the long head of the biceps tendon (LBTH; Fig. 61.5a). The LBTH is marked with stay sutures and incised at the level of the bicipital groove ( Fig. 61.5b). The intraarticular segment of the LBTH is incised sharply from the superior labrum ( Fig. 61.5c). ^{9 , 17} This allows much improved visualization of the fractured fragments ( Fig. 61.5d).

61.6.1 Reduction

The fracture fragments can now be reduced. Using the sutures in the rotator cuff tendons, control of the head and tuberosity fragments is obtained. Additionally, threaded K-wires and 2.5-/4.0-mm Schanz screws can be used as joysticks to assist in the reduction. An Easter plate (DePuy/Johnson & Johnson/Synthes, Paoli, PA) is cut and prebent to accommodate the proximal humeral anatomy and placed on the bone with attention to the axillary nerve ( Fig. 61.6a). Positioning should be performed so the distal screws would be in the most inferior aspect of the greater tuberosity into the allograft. ¹⁷ Vessels branching from the anterior and posterior circumflex arteries are undisturbed by the plating position. ¹⁴ Anterior placement is critical as it avoids vascularity coming into the humeral head. After visual and fluoroscopic confirmation of optimal plate positioning, the plate is distally transfixed with two compression screws ( Fig. 61.6b).

The plate is now used both as template and as subsequent reduction tool, allowing the diaphyseal and metaphyseal fragments to be reduced to the plate. Using pointed reduction (Weber) clamps, the head is now reduced to the plate. Next, the tuberosities are reduced to the head while finetuning the metaphyseal and diaphyseal fragments. Once the plate, humeral head, both tuberosities, and shaft are both visually and fluoroscopically in the correct position ( Fig. 61.6c), two anterior locking screws subsequently are placed as provisional fixation of the head in anticipation of placement of the fibular allograft.

The fibular allograft is then used as an intramedullary nail that fixates the head to the shaft as well as being a secure reinforcement for screws in the osteoporotic bone. ¹⁸ Using a 4.5-mm drill, an entry portal for the fibula allograft is created. The fibula allograft is then gently tamped into the intramedullary canal under fluoroscopy, taking care that the reduced fragments stay in position ( Fig. 61.6d).

The proximal protruding part of the fibula is removed using an oscillating saw under cooling. The fibula allograft is transfixed to the humeral shaft with a 3.5-mm compression screw, capturing the graft within the canal. After radiographic imaging in the AP and lateral views, locked screws can be placed through the plate to secure the head and pass through the fibular allograft. Medial calcar support is acquired by placing locking screws into the inferomedial aspect of the humeral head fragment. ⁴

Proximally, a mixture of locking and standard screws is used to further transfix the head, of which many also capture the fibular allograft. If required, an osteotome can be used to correct calcar alignment during screw fixation ( Fig. 61.6e).

The rotator cuff sutures are then tied to the plate, thereby fixating the greater and lesser tuberosities. The distal end of the LHBT is secured to the plate as tenodesis. A keyhole is drilled in the bicipital groove using a 4.5-mm drill, and the biceps is tunneled into that hole and pulled up to the plate and fixed intraosseously ( Fig. 61.7 ). Wounds are irrigated copiously and the axillary nerve is checked to ensure there is no undue tension. The rotator cuff interval and deltoid interval are closed using absorbable sutures, followed by a meticulous subcutaneous tissue and skin closure.

Related posts:

67 Arthroscopic Reduction and Internal Fixation of Glenoid Rim Fractures 62 Hemiarthroplasty for Proximal Humerus Fractures 63 Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture 68 Open Reduction and Internal Fixation of Midshaft Clavicle Fracture 73 Pectoralis Major Repair 71 Open Acromioclavicular Joint Reconstruction

Stay updated, free articles. Join our Telegram channel

Join