This debate was held in May 2009 in an Orthopaedic Crossfire® session at the 10th Annual Current Concepts in Joint Replacement™ (CCJR) Spring meeting in Las Vegas, Nevada. The CCJR meetings are organized by A. Seth Greenwald, D.Phil. (Oxon) and the Orthopaedic Crossfire® debates serve to frame contemporary controversies and contribute information in a uniquely compelling format within the very popular CCJR meetings (www.CCJR.com).
Dr. Bigliani: “I’ll talk today about four part proximal humerus fractures, and that a humeral head replacement [HHR] is the way to go. The indications for four part fractures for me are lateral displacement of the head in a four part fracture, metaphyseal bone comminution, a dislocation, older osteoporotic patients, and certain head splitting fractures.”
“Case #1: Consider a 68-year-old neurologist with an isolated four part fracture of the proximal humerus. She’s got some osteoporosis, but there’s a lot of medial comminution so this is somebody who I would replace because your first shot is your best shot. We’ve seen that people with malunions don’t do well. A delto-pectoral approach is what I like to use…important to find the biceps and if you can, preserve some of the greater tuberosity with the lesser tuberosity.”
“Big sutures need to go around both the lesser and greater tuberosity to be able to get traction and to be able to pull the rotator cuff out to length. When you do dislodge the head it’s important to keep all the bone…you need bone graft.”
“Case #2: Consider a 46-year-old male who fell from a ladder and sustained a four part fracture. He didn’t have anything done, and went on to a malunion which was treated with a tuberosity osteotomy and a prosthesis in 1983 when Dr. Flatow was a resident with Dr. Neer. At 26 years the patient is satisfied, has 160° of forward elevation, 30° of external rotation, internal rotation of T10, good rotator cuff strength with mild subacromial pain.”
“If we look at the literature, great results when it comes to pain relief and improved function, although it can be variable. In a meta-analysis of 808 patients the Constant Score was 56.63, with tuberosity complications being the biggest factor. Avascular necrosis [AVN] occurs when we revise three and four part fractures previously treated with open reduction and internal fixation [ORIF]. Resch’s work shows a Constant Score of 49.5% with internal fixation. If we use plate fixation we see that 79% have varus angulation, so in my estimation multiple studies over time have demonstrated that HHR for proximal humerus fractures provides reliable pain relief and improved function. Therefore, HHR is a reasonable treatment for the management of four part proximal humerus fractures, especially in older patients.”
Dr. Flatow: “I’m going to speak against this. The question is, ‘Is a big hunk of metal the best treatment for proximal humerus fractures…or can we do better?’ The issue is, ‘Have things changed in the debate between a prosthesis and internal fixation?’”
“It’s hard to debate one’s teacher—and I trained with both Drs. Neer and Bigliani—I will try to debate my mentor with tact and discretion and respect.”
“The results of HHR for fracture are important because if it’s such a miraculous operation then why wouldn’t we want to do it in every case? The literature suggests that there is consistent pain relief, but there is variable function. When it says ‘variable’ in an article it usually means that ‘variable’ is another word for ‘not so good.’ The most common problem is stiffness; the worst problem is failure of tuberosity repair. The ‘old’ thinking is that AVN is a big risk in complex fractures, that AVN is a clinical disaster, that doing an HHR later is very hard, and that doing a HHR first works well.”
“I’ve watched the evolution of these ideas. Dr. Bigliani was once a young man with young thinking; he is now very distinguished in his career and his thinking. But as he has gotten a bit older perhaps he is stuck in this older thinking, and needs to look forward to the recent, ‘young’ thinking that AVN is not always a disaster. We consider the work of Hertel and Jakob where they subdivide AVN risk in four part fractures so that some four parts like a classic dislocated four part have a very high risk of AVN, and others like an impacted valgus fracture with some soft tissue attachment which are on a spectrum with lateral displacement fractures, have less of a risk. Other, more recent concerns are that less AVN occurs with minimally invasive techniques, as Resch and Benirshke have argued. Gerber has argued that AVN is better tolerated if internal fixation is anatomic.”
“I think that AVN is better tolerated in Switzerland than it is in New York City, but his point is that many of the articles about AVN after fracture included people with malunited tuberosities, loose hardware, nerve injuries and scar. And finally, the realization that if you have to do a hemiarthroplasty later, if you did a more minimal internal fixation earlier, the results may be better.”
“So perhaps a classic four part head dislocated fracture is not a good case for internal fixation. But this is not as common as other patterns such as a valgus impacted fracture, which may have a medial hinge. And we’ve learned how to hit it up with elevators and put in pins and place screws in the tuberosity without making incisions, so there’s less scarring. And the lesser tuberosity can be reduced, so the technologies have been expanding. Fixed angle plates can be a problem in these fractures because the screws wind up sticking up in the air if there is collapse.”
“As an example, a patient with a three part fracture was pinned. At 1.5 years she was doing well, but nothing ruins results like follow up, and out at two years she had AVN. But her hemiarthroplasty went almost like a primary osteoarthritic replacement because she had not had a big, open incision at her initial surgery.”
“So percutaneous pinning and minimally invasive surgery (MIS) has become reliable and reproducible, and stiffness is rare. Leesa Galatz, Jerry Williams and I reported on this from three centers, and we have found excellent results, and the AVN rate has been fairly low. Also, the complications are less complicated than after traditional plating, so this has changed some of our thinking because of the lack of scarring in these situations.”
“So proximal humerus fractures…I think there are fewer indications for primary hemiarthroplasty, perhaps true four part dislocations and head splits. MIS/ORIF [open reduction, internal fixation] is growing, and I think late humeral head replacement is certainly an option.”
“Dr. Bigliani has tremendous prestige. He is the president of the American Orthopaedic Association, a prestigious organization…it’s a very old organization. It reminds me of the Freemasons, and so I think there is a rational for some new thinking on this important topic.”
Moderator Thornhill: “Louie, you listed some of the four parts you would replace with a humeral head replacement. Which ones would you repair?”
Dr. Bigliani: “I think Evan’s right…that minimally invasive techniques in younger patients with good bone where their soft tissue attachment sort of escaped the four part classification. When someone gets older, when they have osteoporotic bone, when they just need one operation rather than two…and Evan has been double dipping as you can see from his talk—doing two operations on one patient. When you have older individuals I would go with HHR, but for younger people it’s worth it to try and put it back together. And I’m dead set against these big plates…too much metal, too little bone.”
Moderator Thornhill: “You talk about one or two operations…how about no operations? How about in a valgus impacted four-part, when would you treat the patient nonoperatively?”
Dr. Flatow: “I think a valgus impacted fracture can be tempting to treat nonoperatively because it looks like all the pieces are close together. But the head is usually not at all in contact in the socket and so for an active, healthy person they really don’t do very well. They may be pain free, but they usually don’t have good motion. But unlike a four part with the head and the axila, if you have a demented or a very elderly sick patient, you can get by because it is impacted, the pieces are close together, it’s not going to erode into an artery or cut a nerve. ”
Dr. Bigliani: “There’s a lot of literature out on that and if patients are willing to accept less range of motion and limited function then it’s a reasonable alternative.”
Dr. Flatow: “It works better in Scotland than in Manhattan.”
Moderator Thornhill: “Well, I think under comparative effectiveness we may be facing that even more. Louie, what would be the de minimis x-ray evaluation you want on someone with a four part fracture?”
Dr. Bigliani: “Get the three trauma series views—axillary, lateral in the scapular plane, and an AP view. And you should get a good CT scan. And then you can get more extravagant with other reconstructions, but reconstructions are fairly easy to get right now.”
Moderator Thornhill: “CT scan on everyone with these?”
Dr. Flatow: “I don’t think everyone, but I agree completely with Louie…when there is any question or imprecision I think a CT scan can be very helpful.”
Moderator Thornhill: “What’s harder, a total shoulder or fixing a four part?”
Dr. Flatow: “I think it’s harder to get a good result, so I don’t know about the effort at surgery, but the learning curve and doing a good job with the tuberosities and getting a good result after fracture is a little more challenging than an osteoarthritic total shoulder.”
Dr. Bigliani: “Four part fracture is hard. There are a lot of technical steps that I left out…I just had a patient two years ago who had a massive pulmonary embolism—still alive—and we couldn’t rehab her for awhile. The other thing I want to say is that anatomical fracture in young people really isn’t anatomical. There is always some soft tissue attached and I think those really need to be fixed.”
Moderator Thornhill: “Louie, who exactly should be doing these fractures?”
Dr. Bigliani: “The person that really thinks that he’s qualified to do it. It could be a trauma surgeon or shoulder surgeon…someone who understands the pathology, understands what needs to go into the operation, and understands the rehab.”
Moderator Thornhill: “I think you both agreed that all these fancy new plates and stuff may have some downside, and that minimal is the way to go?”
Dr. Bigliani: “These reconstruction plates…it’s a million screws into osteoporotic bone and it’s probably not the greatest alternative.”
Dr. Flatow: “Shoulders aren’t apples and everyone’s seen that video of the plate with the apple but you can get some bad results with a plate. ”
Moderator Thornhill: “That 26-year-old case had a cemented humeral component…I’ve seen several cases of four parts where in an uncemented humeral component it tends to spin out because you lose the rotational stability with your tuberosities off. Yet the case you showed used cement. When do you decide to cement?”
Dr. Bigliani: “If you’ve got osteoporotic bone and you don’t have good fixation a little cement never hurts.”
Dr. Flatow: “Almost always cement a fracture.”
Moderator Thornhill: “Thank you for a very good discussion, gentlemen.”
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