Name: Cerclage Techniques for Periprosthetic and Proximal Humerus Fractures
Uploaded: 2020-05-08T00:00:00Z
Channel: Arthrex

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VID1-001017-en-US | A | Cerclage Techniques for Periprosthetic and Proximal Humerus Fractures

Evan S. Lederman

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Cerclage Techniques for Periprosthetic and Proximal Humerus Fractures

Hi. My name is Evan Lederman from Phoenix, Arizona, and it's my pleasure to talk to you about trying to avoid periprosthetic fractures and how to fix them if they occur in proximal humerus fractures as well. So intraoperative periprosthetic fractures are genetic. Our goal is to avoid them. But sometimes we can't and we can't avoid them. We need a management strategy. So how common are they? If we look at a number of series retrospective reviews, in this case of over 2000 cases, they found in revision 3.3% risk of an intraoperative periprosthetic fracture, 1% in primaries in this revision series, 3.5%, and in this other series of almost 1000 cases, 3%. So these will happen one out of 30 cases, and you need to be prepared when they happen. Intraoperatively you don't have the benefit of pre-operative planning, and having a system that works for you can be very beneficial. But I'll tell you, I think that these numbers highly underestimate the incidence of periprosthetic fractures. For one, when you try to look back on these things, nobody codes them. They don't always dictate them. Frequently they'll put some cerclage in there and not talk about it in the operative notes. And most of them will heal without issues when properly managed. And in fact, when the reverse shoulder replacement came out, Jill Walsh used to call the exposure the controlled fracture of the proximal humerus as he would crush the front of the proximal humerus to get glenoid exposure. And it was a routine technique in the early days. The goal, of course, is prevention, and to prevent it, we need to understand how it happens. And a nice study by George Atwal and his colleagues. When he was at Mayo Clinic, we identified that there are several issues with regards to the exposure of the glenoid and the humerus, and the presence of revisions and how you put your retractors, how you reduce, how you get the head delivered. These can cause the fractures, and controlling this and doing it yourself rather than your assistance, can avoid getting these fractures in the first place. But then we've all been in the operating room and suddenly we're doing something and we feel a little crack. And then we go through these stages of grieving. And the first thing is denial. It's like, did I really break it? Do I need to do something about this? And then you expose it and it comes to reality that you got to do something. And then the next thing is accepting the fact you're going to be in the operating room another hour and trying to make the life easier for yourself and get something that you can fix. But don't ignore these things. So the most common fracture we get and we get with a fair bit of frequency is a medial calcar fracture, where through broaching or putting in an implant, we'll get a crack in the medial aspect of the bone. The usual treatment will be to use a cerclage cable of some sort, but these fractures are frequently high up in the humerus. And at this, at this area, the humerus is conically shaped, and sometimes the wires will slide down, such as this one on the right where it slid down below. The other tendency is to want to fix these with some cement or go to a different stem. But remember, if you're using the same sized stem and you cement it and you put a cerclage wire in, you might leave the prosthesis proud. So you try to try to avoid making these things worse with the greater tuberosity fracture. The second most common injury you get, particularly in revisions. Also, this is above the top of the medial aspect of the humerus. Frequently, and putting wires around there can be difficult. Sometimes these fracture lines will usually exit right about the level equal to the medial calcar. But sometimes we sometimes we can leverage the design of the implants to put a suture cerclage cable or wire in a position in a position that will stay in place to get these things reduced. And some of the prosthetic systems, particularly the ones we have at Arthrex, have these suture suture holes that give us the ability to hold the sutures at a higher level than the than the cylindrical part of the bone. As we get into these more distal periprosthetic fractures, either intraoperative or post-operatively, the type B's are above the tip of the stem, and the type C's are below. Now we've got to start to get creative. We've got to pull out plates and screws and cables and allografts to do these things. So historically we've used metal cables. These go back a long ways. Stainless steel wires or some type of of multi-fiber cable. And more recently there's been these polymer cables that have been used. But these things have cables or cable clamps that hold them in place. They're big, they're bulky. They don't always go around around bone very easily. And there could be challenges with passing them. So the indications for using cerclage cables are basically any fracture that you can get it around that's not transverse. Whether it's intraoperatively post-operatively fractures that don't involve a stem, and revision situations with osteotomies to remove stems, we use them quite frequently. The challenges are passing them and avoiding iatrogenic injury. Tensioning the cables. Avoiding damage to the bone. Some of these cables can cause metal metallosis or incompatibilities with other metal, particularly plates they can break. The clamps can become painful, and sometimes you can't see around them. So we've introduced the Arthrex FiberTape Cerclage system to try to get around some of these pitfalls. It's suture, so it's flexible. It'll go around around bone very nicely. And it's suture so it's radiolucent. We don't have the clamps to deal with. The system is a folded over doubled FiberTape suture that's swathed together at the end. And the other end has a pre-tied knot, which is a racking hitch stitch. It also has a disposable passer, so you don't need an instrument tray. There are regular traditional passes and then a tensioner as well. The advantages of the FiberTape is it's less irritating to the local soft tissues. It tissues. It is low profile so you can put it above or below a plate. Radiolucent it's very easy to handle and they're fairly inexpensive compared to cables. The FiberStick Cerclage system has been tested. We have a couple of studies that have been done internally showing that the strength is equivalent to cables and stainless steel wires, and in some cases, when it's placed doubled around the humerus, it can be even stronger up to 4000 newtons. And Peter Millett and colleagues did two studies. One was a distraction study where they put the cables and the sutures around a pipe and then pulled it apart. And in this case, they found that the load under tensile load was up to 4000 newtons with the doubled fiber tape suture, which was higher than the stainless steel wires. The second study was to put it around an osteotomy model and drive a wedge down through the humerus to try to break the suture, and it also had favorable results with regards to cyclic loading and low to failure. Superior to stainless steel wire, the technique is pretty simple, and for those of us with A.D.D., look at the lower video, which is really quick. The rest of us can look at the the cadaver model when I do an osteotomy, which is which is what this is. I tend to like to put my sutures around there before I even cut the bone, because it's pretty easy. We have the this is the cable, and you can see the suture on one end is swathed together, and on the other end we have the the pre-tied knot. We have this pretty dull large radius of curvature needle that can be used as a passing notice. There's a suture lead on the back of it. What we do is we put the cable through the eyelet of the needle, and then we'll pull the cable through. We'll leave the trail, suture around the bone, and they'll rethread the swath end of the suture back through a loop in the back of the suture, and then pull the rest of it through. This allows us to double pass the cable around the humerus with only one pass with a passing device, reducing the chance of a genetic injury and making it a little simpler. Once we've passed it, we then take the single end and pass it through the loop and pull it through the the pre-tied knot, which again is a rack and hitch stitch. The nice thing about the racking hitch is it's very easy to tighten and it kind of self locks, so you can hold reduction pretty nicely. We'll usually put 2 or 3 or 3 sutures around for a pair, for a prosthetic fracture or for an osteotomy, and then once the sutures are around, you can tighten them just by pulling the sutures apart. And those of you who have used this knot, it's very nice. We then take the lead off and we feed it into a tensioner. And the tensioner can tighten. We like to tighten to take the slack out of the system. And then once it's tightened, we lay down 1 or 2 half hitches and then re tighten it one more time. And this is a very strong construct. When used in this fashion it's very easy to use. So this is a periprosthetic fracture probably a type B in this case a plate in cerclage was used approximately. You could also use bicortical screws sometimes and we're able to get rigid internal fixation. This is a revision total shoulder arthroplasty with a rotator cuff failure and a glenoid failure. Where an osteotomy was required to remove this long stem. There are three SutureTape FiberTape suture cables around this, and we did get healing in the bone uneventfully. In this case, an extended osteotomy was required to remove this distal cement plug three years later. If you look at the x ray, we have healed bone and you can actually see actually see little indentations in the bone where the cables were. This, to me, suggests that the cables have maintained some tension over time that actually led to some bone remodeling. We've done a retrospective review of 27 arthroplasty cases, three primaries which were periprosthetic fractures and 27 revision cases where suture cerclage was utilized in these cases, with a minimum of a one year follow up. We had a healing of the osteotomy in all cases, with no complications related to the sutures and no reoperations for failure except for a post op periprosthetic fracture. And in the revision cases, two infections for fracture use. This is not a new technique. The technique of using cerclage was the favorite technique in this book, written on fracture management in 1870 as maintaining reduction and using a cerclage for a fracture. Whether it's a long bone fracture or a clavicle or anything, it can basically replace an inter fragmentary screw, and it's quite simple to put in there and can also hold your reduction so you can put your plate on. This is a case from Peter Millett. In this case, he took it, did a close reduction in the operating room, put his plate on. And then if you look at the the middle x ray, the FiberTape suture was placed around along this medial metaphyseal extension. The tensioner is in view and the reduction was pulled into place. And then final fixation was performed. And this has been a nice tool for augmenting these repairs. So in summary avoid fractures in the first place. But if you can't avoid them, we can have a system on the back table that doesn't require a tray that you can open and always have available and not have to wait in case. The tray was used by the trauma surgeons earlier in the day in the presence of a of a at risk, you can put prophylactic cables as well. And I like to put my sutures around before the osteotomy. We have biomechanically validated studies showing that the the sutures are equivalent or better in strength than the metal cables. And you have a lot of versatility with these cables, and they've been a very beneficial addition to my practice. Thank you.

Cerclage Techniques for Periprosthetic and Proximal Humerus Fractures

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