protesebehandling distale humerus frakturer ouh-2011 · •53 shoulders •52 years(18-82) •one...
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Protese Behandling Proximale HumerusFrakturer
A-kursus
Traumatologi
7. Oktober 2011
Lars Henrik Frich MD PhD
Overekstremitets kirurg
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Klinisk problem
- Analyser og beskriv frakturen !- Behandling !- Undgå Caput Nekrose ?
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E.A. Codman 1934
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Fraktur mønstre & Caput Humeri Perfusion
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3 - og 4-Parts Frakturer Komplikationer
• Avaskulærnekrose (AVN)
• Non-union / mal-union
• stifhed• Osteoarthrose
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Indikationer for Fraktur-protese
• 2-parts (Collumanatomicum)
• 3-parts • 4-parts• Head-split
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Collum Anatomicum Fraktur
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Hemialloplastik Behandling
• Få smerter i de fleste tilfælde.
• ROM er mindre forudsigelig
• ADL acceptabel i de fleste tilfælde
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Hemialloplastik Resultater
• Equalis gruppe:• N = 309• Constant Score 73 %• Elevation 100 grader• Malunion/non-union53%
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Wanishing tuberculae
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Ortopædiske fælllesdatabase
• > 5000 skulder proteser
• 300 proteser efter osteosyntesehavari
• Signifikant dårligere resultat efter sekundær protese forsyning
• Dansk skulderalloplastikregister
• Årsrapport 2010
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Proximal Humeral Plating (Philos)
• 53 shoulders• 52 years (18-82)• One surgeon• Follow-up 45 months– 2-part fractures (23)– 3-part fractures (28)– 4-part fractures (2)
JBJS febr. 2008
• COMPLICATIONS:• 36% overall complication rate
• Pt. > 60 years– Screw cutout 43%– Radiographiccomplications 57%
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Philos-ophy
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Revers Skulder alloplastik
• Primær fraktur protese (sydeuropa)
• Sekundær/revisions protese i DK
• Projekt omkring hemi/reversprotese ?
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Vadesteds kirurgi
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Protese Behandling Distale HumerusFrakturer
A-kursus
Traumatologi
7. Oktober 2011
Lars Henrik Frich MD PhD
Overekstremitets kirurg
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Albue Kinematik• Smertefri og stabil bevægelse er fundamental for armens funktion:
• Mindst 100° flexion• Mindst 100°Supination/pronation
Morrey et a.l JBJS 63A:1981
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Når frakturen involverer ledfladen
• Billeddiagnostik– CT (altid)– 3D rekonstruktion– MR (sjældent)
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WorkshopWorkshop
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Kirurgisk Teknik
• “Dorsal side”Incision
• Lateralt omkringOlecranon
• Nerver– Ulnaris– Radialis
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Triceps Sparing/Split
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Olecranon-osteostomi
• “Extra” fraktur• 19% symptomatiske fixationer– Journalagent.com 2009
• Olecranonosteotomi ersjældent nødvendig
• Fix with a plate
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Specielt vanskelige frakturer
• Lave tvær-frakturer• Skærings frakturer• Komminute frakturer• Pseudoartroser
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Lav tværfraktur (f. 1930)
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Type 3 CS Frakturer (f. 1945)
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Dubberly: 2006
Uniquely difficultto repair
Skærings-frakturer
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Komminut fraktur (f.1928)
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Pseudoartrose (f. 1938)
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Primær Albue Alloplastik
Indikationer:
• Komminute og Lave frakturer
• Ustabile pseudoartroser
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Multicenter studie, prospektivt, randomiseret, kontrolleret ORIF vs TER
• 42 patienter• > 60 år• TER bedre ROM• TER bedre MEPS• TER færre komplikationer• TER bedre DASH 3 og 6 måneder
McKee 2009 JSES
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OUH series
• 2009-2011• 5 patienter• Alder 77 år (68-82)• Follow up 16 måneder (3 – 26)
• MEPS 70 – 95 points (max = 100)
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Take Home Message
• Behandling af PHF er en bløddels-operation
• Albuens funktion forudsætter kongruens
• Overvej primær proteseforsyning ved komplexe frakturer hos ældre
• Lav så den CT skanning!
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ThanksThanks
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Lav tværfraktur (f.1928)