A Modified Rotator Cuff Sparing Approach to the Proximal Humerus in Antegrade Nail Osteosynthesis with Transosseous Supraspinatus Tendon RefixationArtikel in mehreren Sprachen: English | deutsch
02. September 2019 (online)
Background Due to the approach within antegrade humerus nail osteosyntheses, lesions of the supraspinatus tendon with a consecutive functional limitation of the rotator cuff (RC), insufficiencies, adhesions and chronic shoulder pain in the long term can result. The evidence respectively the study data situation is limited regarding the evaluation of this issue.
Patients/Material and Methods We are the first to present by means of a case report with a geriatric female patient and a dislocated diaphyseal humerus fracture a rotator cuff sparing osseous approach to the proximal humerus in antegrade nail osteosynthesis without harming the vulnerable supraspinatus tendon (SSP). This is possible through a limited osteotomy of the greater tubercle with the preparation of a 10 mm deep and 15 to 20 mm wide osseous SSP base. The medullary cavity is then opened for inserting the nail in an antegrade manner and closed after fracture stabilization through reposition of the attached osteotomy of the greater tubercle by means of a suture anchor, for example. The procedure also includes a biceps tenodesis. Besides the description of the intraoperative approach and procedure, the clinical and functional results were recorded by established scores as well as radiologically respectively sonographically 6 weeks (T1) and 3 months (T2) postoperatively.
Results The patient was very satisfied regarding pain and function after the modified operative procedure. The rotator cuff tests were negative and there were no impingement like symptoms or indications for an adhesive capsulitis. Range of motion as well as the Constant and (Quick) DASH-Score showed a very good function in the course. The implant was located regularly in the radiological control and the fracture showed a good osseous consolidation. A bland joint without effusion or periarticular fluid and no adhesion with the delta fascia could be presented by sonography. The RC and especially the SSP showed a normal sonographic separation. The functional results are comparable to the other publications so far.
Conclusion The described surgical technique shows a significantly less invasive approach for the implantation of an antegrade humerus nail in the case of a humerus shaft fracture with an excellent function of the affected shoulder in a short-term follow-up. This novel approach should be evaluated by means of prospective studies regarding the functional outcome to justify the establishment of this modified procedure in the long term. Other modified approaches have been depicted but are essentially differing from our described procedure with regards to the invasiveness of the vulnerable tendinous structure of the SSP respectively RC.
- 1 Paech A, Willkomm M, Unger A-C, Heinrichs G. Distale Humerusfraktur. In: Willkomm M. Hrsg. Praktische Geriatrie. 2. vollständig überarbeitete und erweiterte Aufl. Stuttgart: Thieme; 2016
- 2 Lill H, Josten C. [Proximal and distal humerus fractures in advanced age]. Orthopade 2000; 29: 327-341
- 3 Hackl M, Müller LP, Pape-Köhler C. Proximale Humerusfraktur. In: Pape-Köhler C, Stein GM. Hrsg. Unfallchirurgie in der Grund- und Notfallversorgung. Stuttgart: Thieme; 2016
- 4 Grossterlinden L, Ueblacker P, Rueger JM. Arthroscopical findings after antegrade nailing of a proximal humeral fracture: case report and review of the literature. Eur J Trauma Emerg Surg 2007; 33: 383-387
- 5 Brug E, Joist A, Meffert R. [Postoperative radial paralysis. Fate or negligence, conservative wait or revision?]. Unfallchirurg 2002; 105: 82-85
- 6 Baltov A, Mihail R, Dian E. Complications after interlocking intramedullary nailing of humeral shaft fractures. Injury 2014; 45 (Suppl. 01) S9-S15
- 7 Lin J, Shen PW, Hou SM. Complications of locked nailing in humeral shaft fractures. J Trauma 2003; 54: 943-949
- 8 Wilmanns C, Bonnaire F. Rotator cuff alterations resulting from humeral head fractures. Injury 2002; 33: 781-789
- 9 Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev 2011; (06) CD005959
- 10 Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop 2007; 31: 391-395
- 11 Ma J, Xing D, Ma X. et al. Intramedullary nail versus dynamic compression plate fixation in treating humeral shaft fractures: grading the evidence through a meta-analysis. PLoS One 2013; 8: e82075
- 12 Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; (287) 160-164
- 13 Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996; 29: 602-608
- 14 Wali MG, Baba AN, Latoo IA. et al. Internal fixation of shaft humerus fractures by dynamic compression plate or interlocking intramedullary nail: a prospective, randomised study. Strategies Trauma Limb Reconstr 2014; 9: 133-140
- 15 McCormack RG, Brien D, Buckley RE. et al. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br 2000; 82: 336-339
- 16 Gallo RA, Sciulli R, Daffner RH. et al. Defining the relationship between rotator cuff injury and proximal humerus fractures. Clin Orthop Relat Res 2007; 458: 70-77
- 17 Parsch D, Wittner B. [Prevalence of rotator cuff defects in dislocated fractures of the humerus head in elderly patients]. Unfallchirurg 2000; 103: 945-948
- 18 OʼDonnell TM, McKenna JV, Kenny P. et al. Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus. J Bone Joint Surg Br 2008; 90: 61-65
- 19 Verdano MA, Pellegrini A, Schiavi P. et al. Humeral shaft fractures treated with antegrade intramedullary nailing: what are the consequences for the rotator cuff?. Int Orthop 2013; 37: 2001-2007
- 20 Pogliacomi F, Devecchi A, Costantino C. et al. Functional long-term outcome of the shoulder after antegrade intramedullary nailing in humeral diaphyseal fractures. Chir Organi Mov 2008; 92: 11-16
- 21 Gaullier O, Rebaï L, Dunaud JL. et al. [Treatment of fresh humeral diaphysis fractures by Seidel intramedullary locked nailing. A study of 23 initial cases after 2.5 years with rotator cuff evaluation]. Rev Chir Orthop Reparatrice Appar Mot 1999; 85: 349-361
- 22 Gierer P, Scholz M, Beck M. et al. Microcirculatory sequelae of the rotator cuff after antegrade nailing in proximal humerus fracture. Arch Orthop Trauma Surg 2010; 130: 687-691
- 23 Dilisio MF, Fitzgerald RE, Miller ET. Extended Neviaser portal approach to antegrade humeral nailing. Orthopedics 2013; 36: e244-e248
- 24 Knierim AE, Bollinger AJ, Wirth MA. et al. Short, locked humeral nailing via Neviaser portal: an anatomic study. J Orthop Trauma 2013; 27: 63-67
- 25 Christ AB, Gausden EB, Warner SJ. et al. Rotator cuff-sparing approach for antegrade humeral nailing with biceps tenodesis: a technical trick with clinical implications. J Orthop Trauma 2017; 31: e60-e65
- 26 Park JY, Pandher DS, Chun JY. et al. Antegrade humeral nailing through the rotator cuff interval: a new entry portal. J Orthop Trauma 2008; 22: 419-425