78 years old right-handed man after comminuted intraarticular fracture of left proximal humerus (type C1) treated by nail osteosynthesis (Targon PH nail) in year 2016. One month after surgery failure of osteosynthesis on control X-Ray was present. It was treated by explantation of osteosynthetic material and humeral head extirpation. Since the last operation he has suffered from chronic shoulder pain (VAS = 4-5) and marked restricted range of motion of his shoulder (abduction 30°, ventral flexion 45°, eternal rotation 50°). On neurological examination was found lesion of medial brachial plexus fascicle. He is treated by specialist for pain, using opioids and NSAIDs. He is wearing shoulder bandage to support stability of his shoulder and prevent painful shoulder motion. He is still not satisfied with his condition.
Could you recommend me optimal treatment option for this patient?
Glenohumeral arthrodesis with bone graft?
Are there any options for transposition arthroplasty?
Provided there is no infection a reverse total shoulder arthroplasty might be a good option for this patient.
What is the general condition of this patient? Any commorbidities? Why the nail failed? What was the level of function prior to the fracture? What are we try to achieve? Pain relief or restoration of function? What is the cause of pain? The neurological symptomatology ot the pseudarthrosis? What is the general belief regarding the soft tissues in the area? I believe that they will be very stiff and not flexible at all as the movement now happens at the fracture side. What are the patient's expectations? Are they reasonable? When we know all this a plan maybe drawn.
Before embarking on any surgical procedure, the severe osteoporosis has to be taken care of in order to create stronger bed. Pain might be because of generalised debility or osteoporosis and ascertaining the cause and treat it would be better first.
Patient suffered from following chronic diseases such as chronic ischemic heart disease, hypertension, bronchial asthma, chronic atrial fibrillation. On basis on internal and anesthesiology examination we know that the patient can undergo surgery in general anesthesia and we are planing to do it in combination with loco regional anesthesia. Failure of osteosynthesis was result of bed choice of nail implant (Targon PH, B Braun) for the type of fracture (C1). Actual range of motion of his shoulder is abduction 30°, ventral flexion 45°, eternal rotation 50°. Structure of skeleton on X-Ray does not look like osteoporotic. Patient expectation is to decrease pain in his shoulder, that is caused by motion of his left upper extremity (humerus stump is attacking area of glenoid).
The proposed solutions at the original questions are:
Arthrodesis or Transposition arthroplasty.
Arthrodesis will potentially improve pain deriving from the joint but ir will create pain from the neck and I believe that his C.Spine has some degenerative changes judging from the T.Spine portion seen in the second X-ray.
Transposition arthroplasty is providing benefit after a year or more and we need to have some functional rotator cuff, which he may not have due to scaring occurred following the fracture, the two operations and the subsequent mobility of the shoulder through the fracture side.
It is not clear but I have the feeling that the surgeon who removed the nail also created a "Hanging Shoulder" as it is not evident the presence of a humeral head (if there is please accept my apologies for the misinterpretation).
With the view of a painful shoulder and based on the resent clinical presentation if the thought is based on operative treatment there are the possibilities of:
A hemiarthroplasty with extended head articulating with the acromion or a reverse arthroplasty, as already is mentioned.
The former will give some pain relief but not a lot of movement which someone will expect for two reasons; the quality of the soft tissues and the moment arm of the kinetics the prosthesis has
The latter will give some pain relief with also some functional benefits as the rotator cuff is ignored and the movement is achieved by the use of the deltoid.
Further considerations; hemiarthroplasty is technically easier to perform and it is less expensive in comparison with the reverse arthroplasty.
Whatever is done surgically he will have pain which it will come from the acromio-clavicular degenerative joint.
Non-operative solution? Refer to the chronic pain clinic.
I agree with most of the doctors but to think in reverse we have to have at least deltoid an some external rotators cuf or transposition ( bigger surgery)
Thank you all of you for the discussion and your recommendations. After consideration pro and cons in my case, I have decided to make humeroscapular fusion with fibular bone graft (X-rays are attached). Reasons for my decision were following: humeral head extirpation was done 2 years ago, range of motion in patients shoulder was abduction 30°, ventral flexion 45°, eternal rotation 50°, anamnesis of paresis of medial fascicle of brachial plexus, expectation of patient - painless live. Surgery was done on Monday 5th of March. Actually patient is doing well, pain is on level 2 in VAS and he is satisfied with his condition. I will inform you how is the case going.
ok ! thank you very much for the answer ! i will wait for the results...!and congrats for this hard surgery.
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