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Reverse geometry shoulder replacement for metastatic disease of the proximal humerus
96
Abstracts / Injury Extra 43 (2013) 71–127
[2A.20] Review of philos plate fixation in proximal humerus fractures A.C. King ∗ , F. Brooks, R. Williams University Hospital of Wales, Cardiff, United Kingdom Purpose: To review Philos plate fixation at our institution. Methods: We undertook a retrospective review of Philos plate fixation between January 2005 and November 2010. Preoperatively, fractures were classified according to Neer’s classification. First postoperative and most recent AP radiographs were used to assess inferomedial support (presence or absence of calcar screws), adequacy of reduction by measuring the neck-shaft angle, and loss of reduction by measuring the height between the humeral head and the proximal end of the plate. Complications and further procedures were also evaluated on postoperative radiographs. Results: Follow-up was possible in 67 patients, mean age 88 years (range 23–108 years). There were 41 2 part fractures, 23 three part fractures and 3 four part fractures. Fifty five patients had calcar screws in situ (18 with 1 calcar screw, 37 with 2 calcar screws). Mean loss of reduction was 2 mm (3 mm for no calcar screws, 1 mm for 1 calcar screw and 3 mm for 2 calcar screws). Ten patients underwent further surgery for either screw perforation into the joint or plate failure. Mean neck-shaft angle was 131◦ in patients who did not undergo a further procedure (no calcar screw 129◦ , 1 calcar screw 132◦ , 2 calcar screws 134◦ ) compared with 112◦ in patients who underwent revision (no calcar screw 117◦ , 1 calcar screw 120◦ , 2 calcar screws 107◦ ). Conclusion: Results of failed surgical fixation of proximal humerus fractures can be devastating. Previous studies using Philos plates suggest good results. The use of calcar screws has been suggested to provide mechanical support in the inferomedial humeral head and prevent loss of reduction. In our case series, restoration of an adequate neck-shaft angle was the most important determinant in fixation. If this was not achieved, despite adequate inferomedial support, screw perforation or plate failure occurred. http://dx.doi.org/10.1016/j.injury.2012.07.269 [2A.21] Reverse geometry shoulder replacement for metastatic disease of the proximal humerus R. Kapur ∗ , P.A. McCann, P.P. Sarangi Bristol Royal Infirmary, United Kingdom Introduction: The management of skeletal metastases can be challenging for the orthopaedic surgeon. Metastatic involvement of the proximal humerus can be especially debilitating, causing severe pain which leads to loss of function, and pathological fracture which attenuates upper limb function. We present a report of four cases where the use of reverse geometry proximal shoulder prostheses has provided excellent symptomatic relief and a pain free functional range of movement in metastatic proximal humerus disease. Aim: To demonstrate a novel, effective surgical strategy for the management of proximal humeral metastatic disease in elderly patients with concomitant poor rotator cuff function. Methods: A review of the medical records and radiographic imaging who underwent reverse geometry shoulder replacement for metastatic disease of the proximal humerus was performed. Two cases were secondary to breast cancer, the other two of unknown primary. All four patients were referred with severe
shoulder pain significantly limiting range of movement, in one case pathological fracture was demonstrated. Results: In all cases significant symptomatic relief was achieved in the post operative phase, signified by a marked reduction in analgesic requirements. Two patients were completely pain-free at follow up, whilst the remaining two used only minimal oral analgesia. Upper limb function was preserved in all cases, with demonstration of a satisfactory range of motion adequate for activities of daily living in all patients. No surgical complications were noted. Conclusion: The use of reverse geometry shoulder prostheses in proximal humeral metastases (either with or without an associated proximal humeral fracture) demonstrates a reliable and effective method of pain relief with excellent restoration of upper limb function. The unique implant geometry allows the patient to achieve a functional range of motion without reliance on the rotator cuff musculature, which is often defunct in elderly patient groups. http://dx.doi.org/10.1016/j.injury.2012.07.270 [2A.22] The use of a standardised pathway can optimise management and reduce mortality in patient with hip fractures: a prospective audit of 161 patients M. Shenouda ∗ , Z. Silk, S. Radha, W. Radford Chelsea and Westminster Hospital, London, United Kingdom Background: Hip fractures are a major cause of morbidity and mortality in the elderly, and present a challenge to surgical and anaesthetic teams due to the altered physiological state of this population, often combined with multiple co-morbidities. New hip fracture NICE guidelines recommend early orthogeriatric assessment and rapid optimisation of fitness for surgery, aiming to operate within 36 h of admission where appropriate. Following this, a structured hip fracture pathway introduced in our institution to accommodate early orthogeriatric and anaesthetic input aiming at optimisation of patient prior to orthopaedics surgery. Method: Prospective study of 161 patients with fracture NOF performed six months before (92 case) and after (69 cases) introduction of hip pathway. The study looked at patient demography, comorbidity, time to orthogeriatric review (TtG), time to surgery (TtS) and reason in delay, length of hospital stay (LOS) and return to original accommodation and in patient mortality rate. Results: Total of 161 patient studied (92 before introduction of pathway and 69 after). Both groups had quite similar demography. The outcome measures (mean TtG, TtS, LOS and mortality rate) have all decreased following introduction of the pathway for operated cases(150, 93.1%). Mean length of stay decreased by almost 5 days and with further 10% decrease of in-hospital mortality. Smaller proportion of patients waited > 36 h for surgery with majority of delay were due to logistic rather than medical reasons. More patient were returned to their pre-admission accommodation in Hip pathway group (increment of 27%). Pre-operative medical assessment increased from 19% to 85% following this pathway. Conclusion: A hip fracture pathway as part of a multidisciplinary Hip Fracture Programme can enhance the care of patient with fracture NOF, allowing for rapid medical optimisation and earlier surgery, with subsequent reduction in morbidity and mortality. http://dx.doi.org/10.1016/j.injury.2012.07.271
Abstracts / Injury Extra 43 (2013) 71–127
[2A.20] Review of philos plate fixation in proximal humerus fractures A.C. King ∗ , F. Brooks, R. Williams University Hospital of Wales, Cardiff, United Kingdom Purpose: To review Philos plate fixation at our institution. Methods: We undertook a retrospective review of Philos plate fixation between January 2005 and November 2010. Preoperatively, fractures were classified according to Neer’s classification. First postoperative and most recent AP radiographs were used to assess inferomedial support (presence or absence of calcar screws), adequacy of reduction by measuring the neck-shaft angle, and loss of reduction by measuring the height between the humeral head and the proximal end of the plate. Complications and further procedures were also evaluated on postoperative radiographs. Results: Follow-up was possible in 67 patients, mean age 88 years (range 23–108 years). There were 41 2 part fractures, 23 three part fractures and 3 four part fractures. Fifty five patients had calcar screws in situ (18 with 1 calcar screw, 37 with 2 calcar screws). Mean loss of reduction was 2 mm (3 mm for no calcar screws, 1 mm for 1 calcar screw and 3 mm for 2 calcar screws). Ten patients underwent further surgery for either screw perforation into the joint or plate failure. Mean neck-shaft angle was 131◦ in patients who did not undergo a further procedure (no calcar screw 129◦ , 1 calcar screw 132◦ , 2 calcar screws 134◦ ) compared with 112◦ in patients who underwent revision (no calcar screw 117◦ , 1 calcar screw 120◦ , 2 calcar screws 107◦ ). Conclusion: Results of failed surgical fixation of proximal humerus fractures can be devastating. Previous studies using Philos plates suggest good results. The use of calcar screws has been suggested to provide mechanical support in the inferomedial humeral head and prevent loss of reduction. In our case series, restoration of an adequate neck-shaft angle was the most important determinant in fixation. If this was not achieved, despite adequate inferomedial support, screw perforation or plate failure occurred. http://dx.doi.org/10.1016/j.injury.2012.07.269 [2A.21] Reverse geometry shoulder replacement for metastatic disease of the proximal humerus R. Kapur ∗ , P.A. McCann, P.P. Sarangi Bristol Royal Infirmary, United Kingdom Introduction: The management of skeletal metastases can be challenging for the orthopaedic surgeon. Metastatic involvement of the proximal humerus can be especially debilitating, causing severe pain which leads to loss of function, and pathological fracture which attenuates upper limb function. We present a report of four cases where the use of reverse geometry proximal shoulder prostheses has provided excellent symptomatic relief and a pain free functional range of movement in metastatic proximal humerus disease. Aim: To demonstrate a novel, effective surgical strategy for the management of proximal humeral metastatic disease in elderly patients with concomitant poor rotator cuff function. Methods: A review of the medical records and radiographic imaging who underwent reverse geometry shoulder replacement for metastatic disease of the proximal humerus was performed. Two cases were secondary to breast cancer, the other two of unknown primary. All four patients were referred with severe
shoulder pain significantly limiting range of movement, in one case pathological fracture was demonstrated. Results: In all cases significant symptomatic relief was achieved in the post operative phase, signified by a marked reduction in analgesic requirements. Two patients were completely pain-free at follow up, whilst the remaining two used only minimal oral analgesia. Upper limb function was preserved in all cases, with demonstration of a satisfactory range of motion adequate for activities of daily living in all patients. No surgical complications were noted. Conclusion: The use of reverse geometry shoulder prostheses in proximal humeral metastases (either with or without an associated proximal humeral fracture) demonstrates a reliable and effective method of pain relief with excellent restoration of upper limb function. The unique implant geometry allows the patient to achieve a functional range of motion without reliance on the rotator cuff musculature, which is often defunct in elderly patient groups. http://dx.doi.org/10.1016/j.injury.2012.07.270 [2A.22] The use of a standardised pathway can optimise management and reduce mortality in patient with hip fractures: a prospective audit of 161 patients M. Shenouda ∗ , Z. Silk, S. Radha, W. Radford Chelsea and Westminster Hospital, London, United Kingdom Background: Hip fractures are a major cause of morbidity and mortality in the elderly, and present a challenge to surgical and anaesthetic teams due to the altered physiological state of this population, often combined with multiple co-morbidities. New hip fracture NICE guidelines recommend early orthogeriatric assessment and rapid optimisation of fitness for surgery, aiming to operate within 36 h of admission where appropriate. Following this, a structured hip fracture pathway introduced in our institution to accommodate early orthogeriatric and anaesthetic input aiming at optimisation of patient prior to orthopaedics surgery. Method: Prospective study of 161 patients with fracture NOF performed six months before (92 case) and after (69 cases) introduction of hip pathway. The study looked at patient demography, comorbidity, time to orthogeriatric review (TtG), time to surgery (TtS) and reason in delay, length of hospital stay (LOS) and return to original accommodation and in patient mortality rate. Results: Total of 161 patient studied (92 before introduction of pathway and 69 after). Both groups had quite similar demography. The outcome measures (mean TtG, TtS, LOS and mortality rate) have all decreased following introduction of the pathway for operated cases(150, 93.1%). Mean length of stay decreased by almost 5 days and with further 10% decrease of in-hospital mortality. Smaller proportion of patients waited > 36 h for surgery with majority of delay were due to logistic rather than medical reasons. More patient were returned to their pre-admission accommodation in Hip pathway group (increment of 27%). Pre-operative medical assessment increased from 19% to 85% following this pathway. Conclusion: A hip fracture pathway as part of a multidisciplinary Hip Fracture Programme can enhance the care of patient with fracture NOF, allowing for rapid medical optimisation and earlier surgery, with subsequent reduction in morbidity and mortality. http://dx.doi.org/10.1016/j.injury.2012.07.271