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1.
Artículo en Inglés | MEDLINE | ID: mdl-39175656

RESUMEN

Background: Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures. Description: The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling. Alternatives: Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty1. Rationale: The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part humeral fractures, including in elderly patients, when the humeral head fragment remains viable1-5. Expected Outcomes: Based on available Level-III and IV evidence using this technique, patients should expect recovered motion and the ability to perform daily activities independently, with a mean active elevation of 132° to 136°1,4,6, external rotation of 37° to 52°1,4,6, and internal rotation to L31. Pain scores improved significantly from preoperatively to postoperatively, with a mean pain score of 1.4 on the visual analogue scale3,4,6. Patient-reported outcomes were good to excellent, with Single Assessment Numerical Evaluation (SANE) scores of 80% to 81%1,6, mean Constant scores from 71 to 811,3,4,6, and high rates of patient satisfaction (97% satisfied or very satisfied)4. Studies also demonstrated good to excellent fracture healing, with no tuberosity migration and low rates of nonunion (0% to 5%)1,6 and humeral head necrosis (0% to 4%)1,4. Revision rates ranged from 10.5% to 16.7%4,6. Important Tips: The starting position of the guide-pin must be central and at the zenith of the humeral head on the anteroposterior Grashey and the scapular Y views, and the guide-pin must be aligned with the diaphysis prior to advancing it.Failure to bluntly dissect the percutaneous incisions risks injury to the axillary nerve.Verify correct version of the nail prior to drilling any screws, to avoid incorrect version and potential loss of functional rotation. Acronyms and Abbreviations: ABD = abductionAP = anteroposteriorCT = computed tomographyER = external rotationFF = forward flexion (forward elevation)IR = internal rotationSANE = Single Assessment Numerical EvaluationSSV = Subjective Shoulder ValueVAS = Visual Analogue Scale.

2.
JSES Int ; 8(4): 756-762, 2024 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-39035644

RESUMEN

Background: Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures. Methods: A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant. Results: The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 vs. 3- or 4-part, N = 46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n = 4) in 2-part fractures compared to 19% (n = 9) in 3- or 4-part fractures but was not statistically significant (P = .414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures. Conclusion: Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

3.
J Shoulder Elbow Surg ; 33(4): 872-879, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-37689103

RESUMEN

BACKGROUND: Current methods available for assessment of radiolucency and in-between fin (IBF) growth of a glenoid component have not undergone interobserver reliability testing for an all-polyethylene fluted central peg (FCP) glenoid. The purpose of this study was to evaluate anteroposterior radiographs of an FCP glenoid component at ≥48 months comparing commonly used scales to a new method adapted to the FCP. Our hypothesis was that the new method would result in acceptable intra- and interobserver agreement and a more accurate description of radiographic findings. METHODS: We reviewed ≥48-month follow-up radiographs of patients treated with a primary aTSA using an FCP glenoid. Eighty-three patients were included in the review. Radiographs were evaluated by 5 reviewers using novel IBF radiodensity and radiolucency assessments and the Wirth and Lazarus methods. To assess intraobserver reliability, a subset of 40 images was reviewed. Kappa statistics were calculated to determine intra- and interobserver reliability; correlations were assessed using Pearson correlation. RESULTS: Interobserver agreement (κ score) was as follows: IBF 0.71, radiolucency 0.68, Wirth 0.48, and Lazarus 0.22. Intraobserver agreement ranges were as follows: IBF radiodensity 0.36-0.67, radiolucency 0.55-0.62, Wirth 0.11-0.73, and Lazarus 0.04-0.46. Correlation analysis revealed the following: IBF to Wirth r = 0.93, radiolucency to Lazarus r = 0.92 (P value <.001 for all). CONCLUSION: This study introduces a radiographic assessment method developed specifically for an FCP glenoid component. Results show high interobserver and acceptable intraobserver reliability for the method presented in this study. The new scales provide a more accurate description of radiographic findings, helping to identify glenoid components that may be at risk for loosening.


Asunto(s)
Artroplastía de Reemplazo de Hombro , Artroplastia de Reemplazo , Cavidad Glenoidea , Prótesis Articulares , Articulación del Hombro , Humanos , Polietileno , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Artroplastia de Reemplazo/métodos , Reproducibilidad de los Resultados , Estudios de Seguimiento , Resultado del Tratamiento , Diseño de Prótesis , Cavidad Glenoidea/diagnóstico por imagen , Cavidad Glenoidea/cirugía
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