Summary

Reverse arthroplasty of the shoulder with modified L'Episcopo procedure plus transfer of the pectoralis major for handling of complex humeral fracture, but as an option for handling complications of infections, post-tumor resections, osteonecrosis or surgeries of revision of the proximal end of the humerus, where there is currently no other alternative

Abstract

The spectrum of treatment for humeral fractures , will depend on age, activity and fracture characteristics and include from preservation of the humeral head such as percutaneous fixation with wires, osteosynthesis and intramedullary nailing to those of joint replacement such as hemiarthroplasty or full reverse shoulder arthroplasty. Currently, reverse arthroplasty , has been reserved for patients older than 65 with arthroplasty of the rotator cuff and pseudoparalysis with severe pain, in the current literature there are few reports of its use in patients under 50 years, but it seems to be an option in treating young patients with significant impairment of shoulder function with irreparable rotator cuff injuries , post-resection of tumors, infection, arthritis or revision surgeries, where currently there are limited options for reconstruction; these procedures of reverse arthroplasty in young patients should be performed with caution, taking into account the functionality of the deltoid and the restoration of vertical and horizontal forces , mainly in the treatment of complex injuries and it is where the tendon transfers of the pectoralis major muscle and the latissimus dorsi come into play. Case Summary: It is about a 35 years of age male patient, whith proximal humeral fracture Neer IV, resolved surgically ,1 month later, he presents physical and paraclinical signs and laboratory of peri-implant infection, in view of this a total of 4 surgical cleanings were performed and in the latter with positive paraclinical of peri-implant infection and signs of avascular necrosis of the humeral head, it is decided to withdraw the osteosynthesis material. Indicated treatment with antibiotic therapy for 6 weeks with vancomycin. The infections resolved , but in his radiological controls at 6 months evidences complete resorption of the humeral head. One year later presents limited joint ranges with elevation of 20°, external rotation 0°, internal rotation 0°, positive Lag test, positive Hornblower test, positive Bearhug; test score scale constant of 14. The patient is taken to reverse arthroplasty with modified L'Episcopo surgery plus transfer of the major pectoralis with good postoperative results, functional scale of Constant of 70. Currently, after 1 year of evolution the patient is active and does not present signs of prosthetic loosening, with satisfaction and no pain.Discussion: Despite of being only a single case of reverse shoulder arthroplasty with procedure of modified L'Episcopo plus transfer of pectoralis major for handling complication of complex humeral fracture in a young patient with 1 year follow up, the results are clinically acceptable and can considered as an option in the management of infectious complications, post-tumor resections, osteonecrosis or revision surgeries of the proximal end of the humerus, taking into account that the long-term functional outcome is uncertain. Conclusion: We cannot validate the concept of primary reverse arthroplasty of the shoulder with modified L'Episcopo procedure plus transfer of the pectoralis major for handling of complex humeral fractures, but as an option for handling complications of infections, post-tumor resections, osteonecrosis or surgeries of revision of the proximal humerus, where there is currently no other alternative.