65 Arthroscopically Assisted Removal of Proximal Humerus Locking Plates

10.1055/b-0039-167714

65 Arthroscopically Assisted Removal of Proximal Humerus Locking Plates

George C. Balazs and Joshua S. Dines

Abstract

Fractures of the proximal humerus are the third most common fracture in elderly individuals, exceeded only by distal radius and hip fractures. Open reduction and internal fixation with site-specific locking plates remains a common and effective treatment strategy in fractures with unacceptable angulation, displacement, or articular surface involvement. Nonetheless, late complications of treatment are common, including screw perforation into the glenohumeral joint and subacromial impingement with overhead motion. Removal of implants following fracture healing has been shown to improve both pain and function in appropriately selected patients. Plate removal through an open approach, however, carries its own set of complications, such as stiffness, blood loss, neurovascular injury, infection, and refracture. Arthroscopically assisted implant removal has been shown to be a viable alternative technique for removal of implants, minimizing the risk of complications and speeding postoperative recovery. This chapter describes the technique for arthroscopically assisted proximal humerus locking plate removal, reviewing the relevant surgical anatomy and providing tips and tricks to minimize intraoperative risks.

65.1 Goals of Procedure

The goal of arthroscopically assisted removal of a proximal humerus locking plate is to eliminate persistent shoulder pain and dysfunction after fracture healing, while minimizing the morbidity of revision surgery. ¹ ^, ² Despite the increased popularity of arthroplasty, locking plate constructs remain the most common surgical treatment method for fractures of the proximal humerus. Advances in plate design and expanded use of the deltoid-splitting anterolateral approach have improved our ability to achieve and maintain anatomic reduction, even with substantial comminution. However, complications of this treatment modality have been reported as high as 45%, and one-quarter of patients will require a revision procedure, the majority of which are due to symptomatic hardware after healing. ³ ^, ⁴ Stiffness, infection, blood loss, and axillary nerve injury are not uncommon with open plate removal, the impact of which may be magnified in typically elderly patients with medical comorbidities. ⁵ Arthroscopically assisted implant removal minimizes these risks and speeds rehabilitation by limiting the morbidity of revision shoulder surgery. ⁶ ^, ⁷

65.2 Advantages

Arthroscopically assisted proximal humerus locking plate removal minimizes surgical dissection and the size of incisions, decreasing blood loss, and postoperative stiffness.
Because the axillary nerve can be visualized from the subdeltoid space, the risk of neurovascular injury is minimized.
Concurrent arthroscopic examination of the shoulder joint permits assessment and treatment of concurrent intra-articular shoulder pathology.

65.3 Indications

Symptomatic hardware following open reduction and internal fixation of proximal humerus fractures.

65.4 Contraindications

Nonhealed fracture.
Patient is not a surgical candidate.

65.5 Preoperative Preparation/Positioning

Quality preoperative radiographs are necessary to confirm the number and position of screws in the locking plate.
The authors prefer regional anesthesia with sedation to limit anesthetic complications in elderly patients, and facilitate early passive motion immediately after surgery.
Examination under anesthesia is performed on both shoulders to document glenohumeral range of motion.
This procedure can be performed in the beach-chair or the lateral decubitus position, but lateral positioning may interfere with adequate distension of the subdeltoid space, interfering with distal visualization of the plate and increasing the risk of axillary nerve injury during dissection.
- The authors prefer the beach-chair position so this technique is for the beach-chair position.
The nonoperative arm is secured at side, all bony prominences are well padded, and the head is secured.
An arm positioner is helpful to maintain necessary abduction/adduction and rotation during screw removal.
Prep and drape in the usual sterile fashion.