Ulrich Brunner

Dislozierte Mehrfragmentfrakturen des Humeruskopfes Bedeutet die Luxation des Kopffragments eine Prognoseverschlechterung

Problem: The vascularity of the articular fragment is of key importance for the final outcome in three- and four-part fractures of the humeral head. Displacement of the articular segment may compromise the arterial blood supply to the humeral head and result in avascular necrosis. There is still controversy as to whether three- and four-part fracture dislocations (articular fragment outside the glenoid) have an even worse prognosis than displaced three- and four-part fractures. Patients and methods: Between January 1985 and May 1993, 102 patients with three- and four-part fractures of the humeral head were treated by ORIF (mostly tension band wiring) at our institution. In a retrospective study we analysed the functional (Constant 100 point score) and radiological outcome of 67 (66%) of these patients. There were 21 patients with fracture dislocations (FD), n = 5 type B2X, n = 5 type B3X, n = 3 type C2X, n = 8 type C3X, according to the classification of Habermeyer [7]. The ,,X`` represents the dislocation of the articular fragment, whereas the classification to each type is done after reduction of the head. The remaining 46 patients presented with displaced, but not dislocated, three- and four-part fractures (DF), n = 24 type B2, n = 7 type B3, n = 3 type C2, n = 12 type C3. Average follow-up was 25 months (7–72 months). Patients with FD were significantly younger (average age 50 years) than patients with DF (average age 63 years, P < 0.05) and showed a significantly higher incidence of traumatic nerve or plexus lesions (FD 19%, DF 2%, P < 0.05). Results: Concerning the functional results, there was no statistically significant difference between the two groups. The FD patients even showed a slight tendency to better results than patients with DF. This was true for the three-part fractures (average Constant score 78 versus 67 points), as well as for the four-part fractures (average Constant score 62 versus 55 points). The significantly younger age of the FD patients may explain their better results. The entire group of patients with three-part fractures showed a significantly better functional outcome (average Constant score 68 points) than patients with four-part fractures (average Constant score 55 points, P < 0.05). The rate of partial and total avascular necrosis of the humeral head was strongly correlated to the fracture type (number of fragments, fracture of the anatomical or surgical neck, according to the classification of Habermeyer), but again there was no difference between the FD and DF group (B2X: 20%, B3X: 20%, C2X: 33%, C3X: 63%; B2: 25%, B3: 29%, C2: 33%, C3: 67%). Astonishingly, the FD were not associated with an increased rate of avascular necrosis of the humeral head. Three (axillary nerve) out of the five observed primary nerve and plexus lesions had a full neurological recovery after 6–12 months; the two patients with alterations of the brachial plexus showed a slow tendency of improvement at follow-up (12 and 18 months), but still had gross muscular atrophy and impaired sensory function. Conclusion: In displaced three- and four-part fractures of the humeral head the dislocation of the articular segment does not seem to increase the risk of avascular necrosis, if treated by timely and careful ORIF with respect to the vascularity. Even with the increased risk of primary nerve and plexus lesions in fracture dislocations, good functional results can be achieved by early operative nerve decompression and fracture stabilization in this middle-aged patient group. However, older patients with displaced or dislocated four-fragment fractures through the anatomical neck (type C3) have a poor chance of a favourable outcome, and therefore primary prosthetic replacement should be considered.

The fulcrum axis: A new method for determining glenoid version

Previously applied methods for the evaluation of glenoid version did not use body-surface landmarks; therefore, it is not possible to get information about glenoid version from the outside. The tip of the coracoid and the posterolateral corner of the acromion can easily be found on the body surface. These 2 landmarks were connected by a line called the fulcrum axis. After using an experimental x-ray technique in 143 human cadaver scapulae, 5 independent observers identified the fulcrum axis and the glenoid fossa twice. The resulting overall angle between the fulcrum axis and the glenoid fossa was 1.8 degrees (SD 4.5). The fulcrum axis may be used for the preoperative planning and the intraoperative evaluation of glenoid version while performing total shoulder arthroplasties. As the fulcrum axis and the plane of the glenoid fossa are approximately parallel, the fulcrum axis can be used to position patients for performing a true antero-posterior x-ray.

Die Implantation einer Endoprothese bei Humeruskopffraktur

ZusammenfassungOperationszielErsatz des Humeruskopfes mit einer Prothese zur möglichst weitgehenden Wiederherstellung von Form und Funktion des Schultergelenks.IndikationenNicht rekonstruierbare, dislozierte Drei- und Vierfragmentfrakturen des Humeruskopfes.KontraindikationenRekonstruierbarkeit des Humeruskopfes.Fehlende Kooperation des Patienten.OperationstechnikIn halbsitzender Lagerung wird die frakturierte Humeruskopfkalotte über einen deltoideopektoralen Zugang entfernt. Richtige Positionierung der Aequalis-Frakturprothese unter Zuhilfenahme eines schienenartigen Zielgeräts („fracture jig“), mit dem Retroversion und Höhe des Prothesensitzes bestimmt werden können; alternativ oder zusätzlich intraoperative Durchleuchtungskontrolle. Die Tubercula werden mit Spongiosablöcken aus dem entfernten Humeruskopf unterfüttert und mit vier kräftigen horizontalen und zwei vertikalen Nähten refixiert.WeiterbehandlungRuhigstellung im Gilchrist-Verband für 4–6 Wochen bis zur knöchernen Einheilung der Tubercula.ErgebnisseNachuntersucht wurden 13 von 22 Patienten mit primären, d. h. innerhalb von 10 Tagen nach der Fraktur ohne Voroperation implantierten Prothesen und 34 von 50 Patienten mit sekundären Frakturprothesen. Der Nachuntersuchungszeitraum der ersten Gruppe lag bei durchschnittlich 40 (15–70), derjenige der zweiten bei durchschnittlich 44 (8–98) Monaten. Der absolute Constant-Score betrug durchschnittlich 45 bzw. 50 Punkte, der relative Score in beiden Gruppen 56%. Die Patienten waren überwiegend schmerzfrei oder gaben weniger Schmerzen als vor der Operation an (sekundäre Prothesen; p < 0,001). Trotz dieser objektiv nur befriedigenden Ergebnisse war die subjektive Zufriedenheit hoch oder nahm zu (sekundäre Prothesen; p < 0,001). Faktoren, die das Ergebnis beeinflussten, waren in beiden Gruppen besonders die Größe und Stellung der Tubercula (p < 0,001).AbstractObjectiveReplacement of the fractured humeral head with a modular prosthesis. The procedure aims at an adequate reconstruction of shape and function of the shoulder.IndicationsDisplaced three- and four-part fractures of the proximal humerus that cannot be reduced and internally fixed.ContraindicationsFracture can be reduced and adequately internally fixated.Noncompliant patient.Surgical TechniqueIn beach-chair position, the fractured humeral head is removed via a deltopectoral approach. The Aequalis modular fracture prosthesis can be positioned by two methods: (i) a fracture jig optimizing height and retroversion of the prosthesis, (ii) under additional intraoperative fluoroscopy. Healing of the tuberosities can be promoted by cancellous grafts taken from the fractured head. These are fixed by four heavy sutures running horizontally and two sutures running vertically.Results13 out of 22 patients treated by primary hemiarthroplasty (within 10 days after the fracture) and 34 out of 50 patients treated by secondary arthroplasty could be assessed after a mean follow-up of 40 (15–70) and 44 (8–98) months, respectively. The absolute Constant score amounted to 45 and 50 points, respectively, and the relative score to 56% in both groups. The majority of patients was free of pain or suffered less pain than before the operation (secondary arthroplasty; p < 0.001). In contrast to these, only satisfactory, objective results, self-assessment was good or better than before (secondary prostheses; p < 0.001). In both groups, prognostic factors were the size and position of the tuberosities (p < 0.001).

Ortsständige Rekonstruktionstechniken und Palliativoperationen bei großen Rupturen und sogenannten Massenrupturen der Rotatorenmanschette

Die palliativen Verfahren k6nnen often (Operation nach Apoil et al. 1977 [1]) oder arthroskopisch ausgeftihrt werden. Eine vordere oder erweiterte Akromioplastik unter EinschluB einer lateralen Klavikularesektion kommt sowohl bei den rekonstruktiven als auch bei den palliativen Methoden als wesentliches und obligates Operationselement hinzu. Sie dient der Erweiterung des Subakromialraumes und der Verbesserung des Defilee unterhalb des Fornix humeri.

[Periprosthetic humeral fractures: Strategies and techniques for osteosynthesis].

ZusammenfassungDie Prävalenz periprothetischer Humerusfrakturen (PHF) ist derzeit mit 0,6–2,4 % gering. Aufgrund der zunehmenden Primärimplantationsrate ist jedoch eine quantitative Zunahme in naher Zukunft zu erwarten. Die überwiegende Anzahl der PHF ereignet sich im Rahmen der Implantation. Hier ist das Risiko bei zementfreien Schäften sowie Totalendoprothesen erhöht. Weitere Risikofaktoren sind insbesondere das weibliche Geschlecht sowie die Schwere der Komorbiditäten. Postoperative PFH sind mit einer Prävalenz zwischen 0,6 und 0,9 % wesentlich seltener, ursächlich sind hier in der Regel niedrig energetische Stürze. Die Prognose bzw. das funktionelle Outcome nach Revisionsosteosynthese von PHF sind elementar abhängig von der sorgsamen Indikationsstellung, der operativen Versorgung und dem prätraumatischen Funktionszustand der Schulter.Im Armentarium der periprothetischen Osteosynthese am Humerus spielen Cerclagesysteme und winkelstabile Implantate sowie deren Kombination die zentrale Rolle. Bei Trümmerfrakturen mit ausgedehnten Defektzonen, stark ausgedünnter Kortikalis oder ausgeprägten Lysezonen ist die biologische Augmentation der Osteosynthese zu evaluieren. Bei korrekter Indikationsstellung, insbesondere stabil verankerter Prothese, berichten verschiedene Arbeitsgruppen eine hohe knöcherne Ausheilungsrate. Da die Behandlung der PHF komplex ist, sollte sie an dezidierten Zentren durchgeführt werden, um gerade den beim älteren Menschen potenziell vorliegenden Begleiterkrankungen gerecht zu werden.AbstractThe prevalence of periprosthetic humeral fractures (PHF) is currently low and accounts for 0.6–2.4 %. Due to an increase in the rate of primary implantations a quantitative increase of PHF is to be expected in the near future. The majority of PHF occur intraoperatively during implantation with an increased risk for cementless stems and when performing total arthroplasty. Additional risk factors are in particular female gender and the severity of comorbidities. In contrast, postoperative PHF mostly due to low-energy falls, have a prevalence between 0.6 % and 0.9 % and are significantly less common. The prognosis and functional outcome following revision by open reduction internal fixation (ORIF) essentially depend on a thorough assessment of the indications for revision surgery, the operative treatment and the pretraumatic functional condition of the affected shoulder. In the armamentarium of periprosthetic ORIF of the humerus cerclage systems and locking implants as well as a combination of both play a central role. In comminuted fractures with extensive defect zones, severely thinned cortex or extensive osteolysis a biological augmentation of the ORIF should be considered. In this context when the indications are correctly interpreted, especially in the case of a stable anchored stem, various groups have reported that a high bony union rate can be achieved. As the treatment of PHF is complex it should be performed in dedicated centers in order to adequately address potential comorbidities, especially in the elderly population.The prevalence of periprosthetic humeral fractures (PHF) is currently low and accounts for 0.6-2.4%. Due to an increase in the rate of primary implantations a quantitative increase of PHF is to be expected in the near future. The majority of PHF occur intraoperatively during implantation with an increased risk for cementless stems and when performing total arthroplasty. Additional risk factors are in particular female gender and the severity of comorbidities. In contrast, postoperative PHF mostly due to low-energy falls, have a prevalence between 0.6% and 0.9% and are significantly less common. The prognosis and functional outcome following revision by open reduction internal fixation (ORIF) essentially depend on a thorough assessment of the indications for revision surgery, the operative treatment and the pretraumatic functional condition of the affected shoulder. In the armamentarium of periprosthetic ORIF of the humerus cerclage systems and locking implants as well as a combination of both play a central role. In comminuted fractures with extensive defect zones, severely thinned cortex or extensive osteolysis a biological augmentation of the ORIF should be considered. In this context when the indications are correctly interpreted, especially in the case of a stable anchored stem, various groups have reported that a high bony union rate can be achieved. As the treatment of PHF is complex it should be performed in dedicated centers in order to adequately address potential comorbidities, especially in the elderly population.

[Periprosthetic humeral fractures: Strategies and techniques of revision arthroplasty].

ZusammenfassungZiele der Revisionsendoprothetik sind der Erhalt der Knochensubstanz bzw. das Erreichen der knöchernen Konsolidierung sowie der Erhalt einer stabilen Prothesenverankerung mit dem Hauptziel des Wiedererlangens der Schulter-Arm-Funktion. Die Indikation für einen revisionsendoprothetischen Eingriff besteht bei periprothetischer Humerusfraktur in Kombination mit einer Prothesenlockerung. Unabhängig sind bei einliegender anatomischer Prothese weitere Faktoren abzuklären. So sind die sekundäre Glenoiderosion sowie die Rotatorenmanschetteninsuffizienz mögliche Faktoren für ein erweitertes wechselendprothetisches Prozedere. Für die Wechseloperation sind neben dem Explantationsinstrumentarium die Vorhaltung modularer Revisionssets mit Langschäften und Revisionsglenoidkomponenten sowie ein Platten- und Cerclagensystem obligat. Häufig ist trotz gelockerter Prothese ein transhumeraler Schaftausbau mit subpektoraler Fenestrierung erforderlich. Länge und Verankerung des Revisionsschafts müssen die Fraktur mindestens um 2 Schaftdurchmesser überbrücken. Zudem sind häufig Kombinationsverfahren mit additiver distaler Plattenosteosynthese und Kabelcerclagierung sowie eine biologische Augmentation erforderlich. Unter Berücksichtigung einer adäquaten Vorbereitung ist der erfahrene Operateur in der Lage, eine hohe Heilungsrate in Einheit mit einer akzeptablen bis guten Schulterfunktion zu erreichen und weitere Komplikationen zu vermeiden.AbstractThe primary aims when performing revision arthroplasty of periprosthetic humeral fractures (PHF) are preservation of bone stock, achieving fracture healing and preserving a stable prosthesis with the focus on regaining the preoperative shoulder-arm function. The indications for revision arthroplasty are given in PHF in combination with loosening of the stem. In addition, further factors must be independently clarified in the case of an anatomical arthroplasty. In this context secondary glenoid erosion as well as rotator cuff insufficiency are potential factors for an extended revision procedure. For the performance of revision surgery modular revision sets including long stems, revision glenoid and metaglene components as well as plate and cerclage systems are obligatory besides the explantation instrumentation. Despite a loosened prosthesis, a transhumeral removal of the stem along with a subpectoral fenestration are often required. Length as well as bracing of revision stems need to bridge the fracture by at least twice the humeral diameter. Moreover, in many cases a combined procedure using an additional distal open reduction and internal fixation (ORIF) plus cable cerclages as well as biological augmentation might be needed. Assuming an adequate preparation, the experienced surgeon is able to achieve a high fracture union rate along with an acceptable or even good shoulder function and to avoid further complications.The primary aims when performing revision arthroplasty of periprosthetic humeral fractures (PHF) are preservation of bone stock, achieving fracture healing and preserving a stable prosthesis with the focus on regaining the preoperative shoulder-arm function. The indications for revision arthroplasty are given in PHF in combination with loosening of the stem. In addition, further factors must be independently clarified in the case of an anatomical arthroplasty. In this context secondary glenoid erosion as well as rotator cuff insufficiency are potential factors for an extended revision procedure. For the performance of revision surgery modular revision sets including long stems, revision glenoid and metaglene components as well as plate and cerclage systems are obligatory besides the explantation instrumentation. Despite a loosened prosthesis, a transhumeral removal of the stem along with a subpectoral fenestration are often required. Length as well as bracing of revision stems need to bridge the fracture by at least twice the humeral diameter. Moreover, in many cases a combined procedure using an additional distal open reduction and internal fixation (ORIF) plus cable cerclages as well as biological augmentation might be needed. Assuming an adequate preparation, the experienced surgeon is able to achieve a high fracture union rate along with an acceptable or even good shoulder function and to avoid further complications.

Konzepte der Schulterchirurgie

Infektionen am Schultergelenk sind den Angaben der Literatur zufolge eher selten. Dennoch sind eine Reihe von schwerwiegenden, sogar letalen Komplikationen beschrieben [Ambacher et al., 2002], die in erster Linie durch die zu spate Diagnosestellung, verzogert einsetzende Therapie und die topografische Nahe zum Rumpf bedingt sind.

Kombinationsverletzungen von Labrum und Rotatorenmanschette

ZusammenfassungDie radiologische Diagnostik bei Schulterluxation kann sich auf die Traumaröntgenserie (a.-p., y) beschränken, um Frakturen auszuschließen und die korrekte Reposition zu dokumentieren. Eine mangelnde Zentrierung oder degenerative Veränderungen weisen bereits auf mögliche Begleitverletzungen oder Erkrankungen frischer oder älterer Art hin. Bei nach 2–3 Wochen persistierendem Schmerz oder Schwäche bei Abduktion und besonders Außenrotation ist eine Sonographie und oder Kernspintomographie mit der Frage nach Begleitschäden an der Rotatorenmanschette durchzuführen. Die Inzidenz der Begleitrupturen an der Rotatorenmanschette steigt bei Patienten > 40 Jahren > 30%, bei Patienten > 60 Jahren bis > 80%. Bei primär traumatischer Luxation mit Ruptur der Rotatorenmanschette ist in der Regel nur die Naht der Rotatorenmanschette ausreichend. Bei zunehmender Zahl der Rezidive führt dagegen sowohl beim jüngeren als auch beim älteren Patienten die kombinierte superiore und anteriore Stabilisierung zu besseren Ergebnissen. Bei vorbestehenden Massendefekten der Rotatorenmanschette und rezidivierender vorderer Instabilität ist ein Transfer des M. pectoralis indiziert.AbstractIn the case of a shoulder dislocation, standard trauma series (AP / Y) are adequate ¶for radiological diagnosis. Degenerative changes or an excentric position of the humeral head are indicators for additional old or acute pathophysiological problems. If pain and weakness, especially during abduction and external rotation, persist for 2 or ¶3 weeks after repositioning, ultrasonography or MRI is indicated to exclude an accompanying tear of the rotator cuff. The incidence of accompanying rotator cuff tears in cases of anterior or inferior glenohumeral dislocation is in excess of 30% in patients over ¶40 years of age, and may exceed 80% in patients over 60 years of age. Following a first-time traumatic shoulder dislocation prompt operative repair of the acute rotator cuff tear generally leads to satisfactory results. For patients who have suffered a large number of recurrences both a superior and an anterior repair may be indicated, and this leads to better results than a rotator cuff repair alone. In the case of an irreparable rotator cuff defect in combination with a recurrent anterior shoulder dislocation a transfer of the pectoralis major can stabilize the shoulder and restore adequate function.

European Society for Surgery of the Shoulder and the Elbow/American Shoulder and Elbow Surgeons Exchange Fellowship 1994

The1994E h xc ange Fellowship of the European Society for Surgery of the Shoulder and Elbow was designed as the “West Coast Tour.” The data surrounding this 4%week Traveling Fellowship clearly mark this as a most intense educational experience. We visited 7 cities and 16 staff physicians. We gave 17 lectures and observed 42 surgical cases. Last but not least we were invited to 17 dinners and participated in 9 different sport activities. At most of our stops our hosts from the American Shoulder and Elbow Surgeons took outstanding care of our needs and made this fellowship a very unique experience.