Treatment of coronal split glenoid fracture utilizing open reduction internal fixation with immediate intraoperative conversion to rTSA: A Novel approach

Glenoid fractures can be devastating injuries from which many patients do not fully recover. These frequently have residual range of motion limitations, pain, and recurrent instability.13Seidl A.J. Joyce C.D. Acute Fractures the Glenoid.J Am Acad Orthop Surg. 2020 Nov 15; 28: e978-e987https://doi.org/10.5435/JAAOS-D-20-00252Crossref PubMed Scopus (5) Google Scholar Despite awareness these there has been little progress in development novel approaches for treatment glenoid fractures. This is likely secondary to rarity injury, with actual incidence fracture reported as 0.04-0.1% all across age groups.6Hovsepian JM, Dyrna F, Beitzel K. fracture. In: Imhoff AB, Savoie FH III (editors), Shoulder Instability Across Lifespan. Heidelberg, Germany: Springer Berlin; 2017. p.261-268. (ISBN No. 10.1007/978-3-662-54077-0)Google Typically, are treated open reduction internal fixation (ORIF) incongruent joint surfaces, nonoperative management congruent joints. While exact rates posttraumatic arthritis following well defined, appears a consensus that 25% rate post-traumatic glenohumeral impaction increasing after involving greater than 30% surface.6Hovsepian For reasons, up 12.6% ages ORIF later converted total shoulder arthroplasty or reverse (rTSA), relative risk conversion 4.77.16Vander Voort W. Wilkinson B. Bedard N. Hendrickson Willey M. The Operative Treatment Scapula Fractures: An Analysis 10,097 Patients.Iowa J. 2022 Jun; 42 (No doi): 213-216PubMed Given statistics, along our patient’s advanced 76 years old, preinjury osteoarthritis low functional status, method reduction, immediate rTSA was chosen patient. Our patient 76-year-old right-hand-dominant female who sustained ground level fall at home. At time, she feeling her “popping out,” inability lift arm pain. Imaging studies interpreted by emergency department physicians revealed an anterior dislocation (Figure 1). decision made proceed closed under conscious sedation. Successful believed accomplished based on clinical exam physician. Upon reversal sedation, noted re-dislocation right post-reduction radiograph 2).Figure 2Initial Injury film attempted Right Velpeau ViewView Large Image Figure ViewerDownload Hi-res image Download (PPT) Repeat radiographs demonstrated previously overlooked coronal split fracture, fossa mild osteoarthritis. orthopedic surgeon then consulted further evaluation. time consultation, computed topography (CT) scan ordered determine nature pattern degenerative disease 3, 4, 5, 6, 7, 8). found coronally oriented, approximately 40% surface, extension into scapular body centrally oriented fossa.Figure 4Multiple axial cuts CT preoperative planning.View (PPT)Figure 5Multiple 6Multiple 73D Reconstructions GlenoidView 83D Initially, considered due status. However, instability, it deemed inappropriate attempt such because displacement fragment length would remain dislocated while healed. There also thought given idea alone. As stated previously, gold standard treat 4mm surface involvement. ultimately option this multitude reasons least being extended rehabilitation time. During discussions patient, had seeing several bilateral knees undergone rotator cuff repair 8 prior left weakness, limited motion, She said losing function same way, but told candidate now 70s. Additionally, presumed suffered tear high association between dislocations elderly pathology.6Hovsepian Scholar,11Prasetia R. Handoko H.K. Rosa W.Y. Ismiarto A.F. Petrasama Utoyo G.A. Primary traumatic associated elderly.Int J Surg Case Rep. 95107200https://doi.org/10.1016/j.ijscr.2022.107200Crossref (0) reason, team presented repairing injury proceeding “shoulder replacement” decreasing function. understanding options agreed proposed plan ORIF. Due comminution present scan, augments revision components necessary operation bone stock available sufficient. After preparing draping according sterile procedure, identifying appropriate landmarks, exposed using deltopectoral approach. Attention turned humerus. exposure, humerus without Hill-Sachs lesion, however, massive included entire supraspinatus superior aspects both infraspinatus subscapularis, moderate articular cartilage. presence obvious changes seen humeral head felt assured correct. Retractors were placed canal blunt awl. reamed progressively until snug fit proper “chatter” appreciated. resected ten degrees retroversion. A protective plate over prepared reduced back capsule. expose full 360 glenoid. discovered involved 50% damage Through direct visualization, manual tentatively held place point-to-point tenaculum. adequate achieved, K-wire posterior aspect line. 3.5mm cannulated drill near cortex drilled. 2.7mm far screw lag-by-technique fashion, compression process repeated inferior fragment, keeping mind need allow space central peg glenosphere baseplate pass screws. confirmation guide wire drilled through center glenoid, two lag screws, reaming surface. power reamer used bleeding subchondral bone. Peripheral carried out manually. sized no interference either screws placing peg. superior, inferior, secure baseplate. done trial-and-error basis directly visualizing trajectory aiming away their projected course. able inference subsequent placed. screw, second attempted. successful drilling, appeared some again position. three each resulting obstruction previous upon returned size stem reconfirmed cemented place. +3 spacer trialed, stability. final polyethylene +9 wound implants irrigated. Unfortunately, subscapularis unable repaired lack tendon remnant excessive lateralization lesser tuberosity caused inclusion spacer. surrounding soft tissue sequential fashion. tolerated procedure non weight bearing upper extremity immobilizer weeks. postoperative well-fixed prosthesis 9). neurovascularly intact day one when interscalene block worn off. discharged home three. followed clinic ten, pain control. Her remained since discharge, change post protocol generally allowed begin passive first follow-up appointment. staples removed, advised pendulum swings, intermittently remove immobilizer, hang gravity. Radiographs obtained visit healing stable, well-located prosthesis. 10, 11) visit, course typical additional precautions outcomes similar electively.Figure 11Postoperative 10 office view shoulderView next six weeks postoperatively. active evaluated. 110 forward flexion, 15 external rotation, rotation iliac crest. 5/5 strength flexion 3/5 rotation. 12, 13) return activity. 6 weeks, scheduled month follow-up.Figure 13Postoperative week visit: Axillary View ShoulderView six-month results exceeding average underwent elective could flex 165 degrees, externally rotate 45 internally L2, movement compared contralateral shoulder. denied any sensation instability procedure. healed 14, 15).Figure 15Postoperative All measurements taken throughout senior performed utilizing goniometer measurements. American Elbow Surgeons score (ASES) 80/100.4Forlizzi J.M. Puzzitiello R.N. Hart P.A. Churchill Jawa A. Kirsch Predictors poor excellent arthroplasty.J Feb; 31: 294-301https://doi.org/10.1016/j.jse.2021.07.009Abstract Full Text PDF (6) Scholar,12Sallay P.I. Reed L. measurement normative scores.J 2003 Nov-Dec; 12: 622-627https://doi.org/10.1016/s1058-2746(03)00209-xAbstract currently remains complication modest follow-up. year evaluate stability intra-articular consistent literature years.1Anavian Gauger E.M. Schroder L.K. Wijdicks C.A. Cole Surgical operative complex displaced fractures.J Bone Joint Am. 2012 Apr 4; 94: 645-653https://doi.org/10.2106/JBJS.J.00896Crossref (73) Scholar,6Hovsepian Scholar,8Königshausen Coulibaly M.O. Nicolas V. Schildhauer T.A. Seybold D. Results non-operative fossa.Bone 2016 Aug; 98-B: 1074-1079https://doi.org/10.1302/0301-620X.98B8.35687Crossref (16) current step off >4mm >20% lip Non-operative nondisplaced non-weight-bearing affected sling 6-8 review relevant reports good young patients, work nearly every circumstance.1Anavian >65 preexisting pathology tend poorer nonoperatively alone8Königshausen Scholar. Furthermore, go undergo rTSA. In case, most closely resembled Ideberg 1b,7Ideberg Grevsten S. Larsson Epidemiology Incidence classification 338 fractures.Acta Scand. 1995 Oct; 66: 395-397Crossref substantial involvement (approximately 40-50%) complained injury. inevitable increase preoperatively use stabilize before CT. strong enough us ream displacing By directing posterior, base we reasonable security. When comparing receiving OA, flexion(FF) rotation(ER) comparable (110 vs 120 FF, 30 ER) months postoperatively (165 140 40 ER).6Hovsepian Scholar,9Krupp Ma C.B. Nyland Getz C. Srinivasan Reverse function: new perspectives 10-year multicenter study 7-year follow-up.Arch Trauma 27; https://doi.org/10.1007/s00402-022-04702-zCrossref Scholar,10Norris T.R. Iannotti J.P. Functional outcome primary osteoarthritis: study.J 2002 Mar-Apr; 11: 130-135https://doi.org/10.1067/mse.2002.121146Abstract (349) Scholar,14Shah S.S. Gaal B.T. Roche A.M. Namdari Grawe B.M. Lawler et al.The modern updated systematic complication: part I.JSES Int. Sep 7; 4: 929-943https://doi.org/10.1016/j.jseint.2020.07.017Abstract (25) located minimal six-week six-months. ASES 80/100, undergoing OA4Forlizzi younger - Anavian al mean 44 old still comparatively. received regain 151 105 abduction, 52 ER, IR T5 minimum 12 months1Anavian FF 165, ER 45, L2 follow, old. Even though described report rare, few describing within 2 .15Smith T. D'Alonzo Arevalo Kazanjian Isolated Fracture Glenohumeral Dislocation Elderly: Novel Indication Arthroplasty.Case Rep Orthop. Aug 12; (8826803): 2020https://doi.org/10.1155/2020/8826803Crossref case published well. Both publications demonstrate option. single patient's follow-up, reports, suggests viability treatment. technique may large demand 65 and/or concerns.