Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures

Proximal humerus fracture sequelae: are corrective osteotomies still a taboo? The role of three-dimensional preoperative planning and patient-specific surgical guides for proximal humerus corrective osteotomy in combination with reverse shoulder arthroplasty

Background

Symptomatic proximal humeral fracture sequelae (PHFS) represent a surgical challenge due to the altered bone and soft tissue morphology. The purpose of this study was to report the outcome of Multiplanar Corrective Humeral Osteotomies (MCHOs) in combination with reverse total shoulder arthroplasty (rTSA) performed following a three-dimensional (3D) preoperative planning and using a 3D-printed patient-specific surgical instrumentation (PSI) in type 1C, 1D, and 4 PHFS.

Methods

In this prospective monocentric study, we enrolled patients affected by symptomatic PHFS type 1C, 1D, or 4 of Boileau's classification, treated between 2018 and 2019 with rTSA associated to MCHO and followed-up at 12 and 24 mo. The preoperative and postoperative Constant Score (CS), visual analog scale, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded. All patients underwent a preoperative computed tomography, then a dedicated software was used to run a segmentation algorithm on computed tomography images. Metaphyseal bone cuts were virtually performed before surgery in all patients, and a 3D-printed PSI was used to reproduce the planned osteotomies in vivo.

Results

Twenty patients completed a 2-y follow-up. The mean (± standard deviation) CS, visual analog scale, and DASH values improve from 24.3 (± 8.8), 6.5 (± 1.3), 60.7 (± 9.6) preoperatively, to 67.7 (± 11.4), 1.6 (± 0.8), 24.1 (± 13.1) points after surgery, respectively. The minimally clinical important difference for CS and DASH score was achieved in 95% of patients. No major complication was observed. One patient showed an unexplained worsening of clinical scores between the 12 and the 24-mo follow-up, while in one patient bone resorption of the greater tuberosity was observed on radiographs at 2 y, with no clinical impact.

Conclusion

The combination of preoperative 3D planning and intraoperative use of 3D-printed PSI to perform MCHO as concurrent procedure in the context of rTSA in the treatment of Boileau type 1C, 1D, and 4 PHFS may lead to a satisfactory clinical outcome at 2 y of follow-up.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

INTRODUCTION

The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.

METHODS

A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.

RESULTS

Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication.

CONCLUSIONS

Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.

Reverse Shoulder Arthroplasty for Malunions of the Proximal Part of the Humerus (Type-4 Fracture Sequelae)

BACKGROUND

The treatment of fracture sequelae of the proximal part of the humerus in combination with posttraumatic arthritis is challenging. The reported results of treatment with anatomic shoulder arthroplasty are disappointing. The aim of this multicenter study was to analyze the clinical and radiographic results of reverse shoulder arthroplasty for treatment of posttraumatic sequelae of the proximal part of the humerus with malunion of the tuberosities.

METHODS

This was a retrospective, multicenter study of 42 patients (42 shoulders) with the diagnosis of posttraumatic sequelae of the proximal part of the humerus with malunions of the tuberosities who were treated with reverse shoulder arthroplasty between 2000 and 2010. The mean age at the time of arthroplasty was 68 years (range, 27 to 83 years; median, 70 years). The dominant side was treated in 24 cases. The mean clinical and radiographic follow-up was 4 years (range, 2 to 13 years; median, 3.5 years). The Constant score including subgroups, shoulder flexion, rotation motion, and radiographs of the affected shoulders were analyzed before the surgical procedure and at the time of the latest follow-up. Patients categorized their postoperative results as very good, good, satisfactory, or unsatisfactory.

RESULTS

The mean Constant score increased from 19.7 points (range, 0 to 52 points) preoperatively to 54.9 points (range, 21 to 83 points) postoperatively (p < 0.0001). All of the subgroups of the Constant score also increased, as did active shoulder flexion and external rotation (all p < 0.0001). In one case, loosening of the humeral and glenoid components occurred. Scapular notching was present in 22 shoulders (52%) and was grade 1 in 12 cases, grade 2 in 4 cases, grade 3 in 2 cases, and grade 4 in 4 cases. Complications occurred in 4 patients (9.5%). Eighteen patients (43%) rated their result as very good, 19 (45%) rated their result as good, 4 (10%) rated their result as satisfactory, and one (2%) rated the result as unsatisfactory.

CONCLUSIONS

Reverse shoulder arthroplasty is a viable treatment option for type-4 proximal humeral fracture sequelae that cannot otherwise be treated with anatomic shoulder replacement.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory.

An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure.

Cite this article: Bone Joint J 2015;97-B:967–72.

Anatomic shoulder arthroplasty for treatment of proximal humerus malunions

BACKGROUND

Malunion of proximal humeral fractures complicated by damage to the glenohumeral cartilage and injury to the joint capsule and rotator cuff can include treatment requiring anatomic shoulder arthroplasty. This study defines results and complications of this procedure and identifies factors associated with success or failure.

METHODS

From 1976 to 2007, 109 patients underwent shoulder arthroplasty for proximal humerus malunions. Ninety-five met the criteria for analysis with a mean follow-up period of 9.2 years. Fracture types according to the Neer classification were two part in 20, three part in 37, four part in 31, and head splitting in 2, with 16 fracture-dislocations. Hemiarthroplasty was performed in 45 patients, with 50 undergoing total arthroplasty.

RESULTS

Pain scores improved from 7.8 to 3.1 (P < .001). The mean active elevation and external rotation improved from 69° to 109° and from 8° and 39°, respectively (P = .001). Of 31 patients with available radiographs, 20 had healed tuberosity osteotomies. Sixteen complications required 10 reoperations, including 6 of 9 patients with severe postoperative instability. There were 57 excellent or satisfactory results by use of the Neer rating. No patient, injury pattern, previous treatment, surgical, or radiologic variation was significantly associated with an increased risk of an unsatisfactory result, except for severe postoperative instability. Kaplan-Meier survivorship for reoperation, in 109 shoulders, was 94.8% (95% confidence interval, 90.5%-99.4%) at 5 years and 90.1% (95% confidence interval, 83.6%-97.1%) at 10 and 15 years.

CONCLUSION

Anatomic shoulder arthroplasty improves pain and motion. Surgery is complex. Tuberosity osteotomies often heal. Postoperative instability is the most common complication leading to reoperation and is usually associated with rotator cuff and shoulder capsule injury.

Management of malunion of the proximal humerus: current concepts

Proximal humerus fractures remain one of the most common orthopaedic injuries, particularly in the elderly. Displaced fractures often require surgery, and management can be challenging because of comminution and poor bone quality. Despite advances in surgical technique and implant design, reoperation for malunion or nonunion of the tuberosity (arthroplasty) or screw penetration (open reduction and internal fixation) remains problematic. Recent studies have demonstrated acceptable results following nonsurgical management of displaced proximal humerus fractures in elderly, low-demand patients. In younger, more active patients, reduced function and pain that accompany select proximal humeral malunions are generally poorly tolerated. Surgical options for symptomatic, malunited tuberosities include osteotomy, tuberoplasty with rotator cuff repair and subacromial decompression, or decompression alone. Surgical neck malunion can be managed with corrective osteotomy and preservation of the native joint. Arthroplasty is reserved for complex malunions with joint incongruity. Surgical management of symptomatic proximal humeral malunion remains challenging, but good outcomes can be achieved with proper patient selection.

Results of uncemented hemiarthroplasty as primary treatment of severe proximal humerus fractures in the elderly

OBJECTIVES

The purpose of this study was to analyze functional and radiologic results of a consecutive series of elderly patients who underwent uncemented hemiarthroplasty as primary treatment of complex proximal humeral fractures.

METHODS

Twenty-one patients with severe proximal humerus fracture (three or four fragments and three- or four-fragment fracture dislocations) were treated with uncemented proximal humerus hemiarthroplasty. Patients were evaluated using the Constant-Murley Score, the Quick scale Disabilities of Arm, Shoulder and Hand (Quick-DASH) Score, range of motion, residual pain, radiographic parameters, and complications including clinical and radiologic data of mobilization.

RESULTS

After a mean postoperative period of 20.57 months (range 12-42 months), the mean Constant-Murley Score was 44 points (20-57), the mean Quick-DASH score was 24 points (16-39), postoperative pain according to a mean visual analogue scale was 1 (0-8), active abduction was 50° (30-135), and active flexion 70° (20-120). There were no cases of infection, deep vein thrombosis, dislocation, blood transfusions, or reoperation because of prosthetic loosening. Bivariate analysis of demographic data, radiologic findings, and other variables showed associations between duration of surgery and a higher Quick-DASH score (0.606; p = 0.037), and the number of sessions of rehabilitation with a higher Quick-DASH score (0.708; p = 0.015).

CONCLUSIONS

The results of treatment of severe proximal humerus fractures in the elderly with an uncemented hemiarthroplasty are safe and promising; however, a comparative cohort study (cemented vs. uncemented) and long-term follow-up are still needed.

Late prosthetic shoulder hemiarthroplasty after failed management of complex proximal humeral fractures

Background. The purpose of this study was to report our experience with shoulder hemiarthroplasty in the context of old trauma. Methods. 33 patients with failed treatment for a complex proximal humeral fracture underwent prosthetic hemiarthroplasty. There were 15 men and 18 women with a mean age of 58.1 years. The average period from initial treatment was 14.9 months. Sequelae included 11 malunions, 4 nonunions, 15 cases with avascular necrosis (AVN) and 3 neglected posterior locked dislocations. Follow up investigation included radiological assessment and clinical evaluation using the Constant score and a visual analogue pain scale. Results. After a mean follow up of 82.5 months the median Constant score was 75.7 points, improved by 60% in comparison to preoperative values. Greater tuberosity displacement, large cuff tears and severe malunion were the factors most affected outcome. No cases of stem loosening or severe migration were noted. 60% of the patients were able to do activities up to shoulder level compared with 24% before reconstruction. Conclusions. Late shoulder hemiarthroplasty is technically difficult and the results are inferior to those reported for acute humeral head replacement, nonetheless remains a satisfactory reconstructive option when primary treatment fails.

Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae)

BACKGROUND

The aim of this study was to evaluate the prognostic factors and limitations of anatomic unconstrained shoulder arthroplasty, performed without tuberosity osteotomy, for the treatment of secondary glenohumeral arthritis following posttraumatic cephalic collapse or necrosis of the humeral head, defined as type-1 fracture sequelae.

METHODS

Fifty-five patients with type-1 fracture sequelae treated with anatomic shoulder arthroplasty were included in this retrospective single-center cohort study. All anatomic humeral prostheses were implanted without performing a greater tuberosity osteotomy. Glenoid resurfacing was performed in forty-four patients (80%). Clinical and radiographic analysis was performed at a mean of fifty-two months (range, twenty-four to 180 months) postoperatively.

RESULTS

Four reoperations (7%) were performed, including two revisions in patients who required glenoid resurfacing because of glenoid erosion after hemiarthroplasty. At the time of the latest follow-up, 93% of patients were satisfied or very satisfied, and the mean Subjective Shoulder Value (SSV) was 81%. There were significant improvements in the mean Constant score (from 32 to 69 points), active anterior elevation (from 88° to 141°), external rotation (from 6° to 34°), and internal rotation (from the buttock to L3). Significantly poorer results were associated with proximal humeral deformity in varus and with fatty infiltration of the rotator cuff muscles. Patients with proximal humeral deformity, specifically varus or valgus malunion of the greater tuberosity, had a mean Constant score that was 10 points lower and active elevation that was almost 20° less than patients with no such deformity. The poorest results were observed in patients with varus malunion.

CONCLUSIONS

Our study confirmed that the outcomes of anatomic shoulder arthroplasty for the treatment of type-1 fracture sequelae are good and predictable when deformation of the proximal humerus is acceptable(i.e., when no greater tuberosity osteotomy is necessary). The results were negatively affected by proximal humeral varus deformity and by fatty infiltration of the rotator cuff on imaging studies. In such cases, reverse shoulder arthroplasty may be more appropriate, especially in elderly patients.

Shoulder hemiarthroplasty: outcomes and long-term survival analysis according to etiology

BACKGROUND

The indications for hemiarthroplasty in glenohumeral joint diseases remain controversial and depend mainly on the original underlying diagnosis. Our objective was to investigate the influence of the primitive aetiology on long-term prosthesis survival and on the Constant-Murley score.

MATERIALS AND METHODS

We studied 272 shoulders with the following diagnoses: fracture sequelae (n=73), primary osteoarthritis (n=67), cuff tear arthropathy (n=43), avascular necrosis (n=40), rheumatoid arthritis (n=31), and other (n=18). Of the 272 shoulders, 139 were evaluated after at least 8 years (mean follow-up, 134 months). In all, 30 prostheses required removal. Functional status was evaluated using the Constant-Murley score and survival rate using the Kaplan-Meier method with prosthesis removal or conversion to total arthroplasty as the endpoint.

RESULTS

Ten-year prosthesis survival was 88.13% overall, 100% in the rheumatoid arthritis group, 94.9% in the avascular necrosis group, 94.2% in the primary osteoarthritis group, 81.5% in the cuff tear arthropathy group, and 76.8% in the fracture sequelae (P=0.05). The mean Constant-Murley score after 8 years or more was 70.1 in avascular necrosis, 60.7 in primary osteoarthritis, 57.7 in fracture sequelae, 55.3 in rheumatoid arthritis, and 46.2 in cuff tear arthropathy (P=0.0006). The complication rate with the initial population as the denominator was 24.7% in fracture sequelae, 18.6% in cuff tear arthropathy, 15% in avascular necrosis, 8.9% in primary osteoarthritis, and 3.2% in rheumatoid arthritis.

CONCLUSIONS

The best indication for shoulder hemiarthroplasty is avascular necrosis and the worst indications are cuff tear and post-traumatic fracture sequellae. Rheumatoid arthritis and primary glenohumeral osteoarthritis are good indications in patients younger than 50 years of age.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Unconstrained shoulder arthroplasty for treatment of proximal humeral nonunions

BACKGROUND

Unconstrained shoulder arthroplasty is one of several methods for treatment of proximal humeral fracture nonunions. The goal of this study was to define the results and complications of this procedure.

METHODS

From 1976 to 2007, sixty-seven patients underwent unconstrained shoulder arthroplasty for proximal humeral nonunion and were followed for more than two years. There were forty-nine women and eighteen men with a mean age of sixty-four years and a mean duration of follow-up of nine years (range, two to thirty years). The fracture type according to the Neer classification was two-part in thirty-six patients, three-part in sixteen, and four-part in fifteen. Hemiarthroplasty was performed in fifty-four patients and total shoulder arthroplasty was done in the remaining thirteen.

RESULTS

There were thirty-three excellent or satisfactory results according to the modified Neer rating. Tuberosity healing about the prosthesis occurred in thirty-five shoulders. The mean pain score improved from 8.3 preoperatively to 4.1 at the time of follow-up (p < 0.001). The average active shoulder elevation and external rotation improved from 46° and 26° to 104° and 50° (p < 0.001). Shoulders with anatomic or nearly anatomic healing of the tuberosities had greater active elevation at the time of final follow-up (p = 0.02). There were fourteen complications in twelve patients, with twelve reoperations including five revisions. Kaplan-Meier survivorship with revision as the end point was 97% (95% confidence interval [CI]: 94.3, 100) at one year and 93% (95% CI: 88.0, 99.2) at five, ten, and twenty years.

CONCLUSIONS

Shoulder arthroplasty decreases pain and improves function in patients with a proximal humeral nonunion. However, the overall results are satisfactory in less than half of the patients. Tuberosity healing is inconsistent and influences the functional outcome.

Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning

PURPOSE

To report the mid- to long-term results of arthroscopic tuberoplasty and rotator cuff retensioning for proximal humerus malunion.

METHODS

Between August 2001 and October 2009, 9 patients with a mean age of 49 years underwent shoulder arthroscopy with tuberoplasty and rotator cuff advancement for malunion of the proximal humerus and were included in this study. The mean delay between the initial fracture and our surgery was 19 months. We developed a systematic technique to take down the rotator cuff over the malunited proximal humerus, perform a tuberoplasty, and then retension and repair the rotator cuff by advancing it on the greater tuberosity. The mean follow-up was 50 months (range, 12 to 108 months).

RESULTS

Patients showed mean active forward elevation of 164° (range, 90° to 180°; gain of 43°), recovery of mean active external rotation of 45° (range, 30° to 60°; gain of 16°), and a mean pain score of 1.8 points (range, 0 to 5 points; reduction of 3.8 points). The overall functional results according to the University of California, Los Angeles score were excellent in 3 cases, good in 3, and fair in 3. No patient required additional surgery. Of the 9 patients, 8 (89%) were able to return to their previous sports or activities. All patients declared themselves as being satisfied with the result.

CONCLUSIONS

Arthroscopic tuberoplasty and rotator cuff retensioning for proximal humerus malunion comprise a viable alternative to traditional open methods, particularly in young patients. A comprehensive approach is recommended that addresses stiffness, associated pathology, and impingement, and re-establishes rotator cuff function. Although the technique is technically demanding, it allows preservation of the native humeral head, is associated with a very low complication rate, and avoids concerns about long-term prosthetic survival in young patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus

BACKGROUND

Experience treating proximal humerus fracture sequelae with reverse total shoulder arthroplasty is limited. We report our results.

PATIENTS

Forty-four patients with sequelae of a proximal humeral fracture were treated with a reverse total shoulder prosthesis. There were 26 women and 18 men, with a mean age of 77 years (range, 74-84 years). The mean follow-up after reverse arthroplasty was 48 months (range, 40-84 months).

RESULTS

The mean Constant score increased from 28 preoperatively to 58 postoperatively (p < 0.0001). The average anterior elevation increased from 40° to 100° (p < 0.0001), abduction from 41° to 95° (p < 0.0001), external rotation from 15° to 35° (p < 0.0001) and internal rotation from 25° to 60° (p < 0.0001). The average subjective shoulder score increased from 13% preoperatively to 56% postoperatively (p < 0.0001). All but six patients would undergo the same procedure again if faced with the same problem. Twenty-four patients were very satisfied, 14 satisfied and 6 unhappy with the operation. Six prosthetic dislocations occurred (13.6%). Two of them were successfully treated by adding an extension to the humeral neck component to increase the offset and tension. In the other four dislocations this procedure failed, and the prosthesis was revised and converted to a hemiarthroplasty. There was one case of glenoid component loosening that was converted to a hemiarthroplasty.

CONCLUSIONS

The reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the dislocation rate is high.

Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus

INTRODUCTION

Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters.

METHODS

A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05.

RESULTS

In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate.

CONCLUSION

Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.

Outcomes, and factors affecting outcomes, following shoulder hemiarthroplasty for proximal humeral fracture repair

BACKGROUND

Hemiarthroplasty has been applied to treat proximal humeral fracture with variable outcomes. The purpose of this retrospective study was to assess factors affecting outcome in patients following hemiarthroplasty for proximal humeral fracture (PHF) repair.

METHODS

Patients with proximal humeral fractures treated over a 6-year period were included. Indications for hemiarthroplasty were severe three-part fractures associated with osteoporosis; four-part fractures with or without dislocation; splitting of the humeral head, or >45% collapse of the humeral head. Surgery outcome and postoperative complications were main outcome measures in this study.

RESULTS

Thirty-three of 47 patients were included in the final analysis (mean age 64.3 years, range 43-82). Mean postoperative follow-up was 44.4 (range 36-57) months. Postoperative complications (shoulder dislocation, mild shoulder subluxation, heterotopic ossification) occurred in seven patients. Healing of the greater and lesser tubercles was abnormal or poor in 18 patients. These patients had significantly higher pain scores (4.0 ± 1.1 vs. 2.2 ± 1.1) and significantly lower capacities for active lifting (79.3 ± 9.6 vs. 121.7 ± 24.3), external rotation (20.7 ± 3.7 vs. 39.2 ± 10.3), and Neer scores (79.2 ± 5.7 vs. 90.6 ± 3.6) versus patients who exhibited complete healing (all P < 0.001). Patient age, type of surgical approach, and fracture type were not major influencers of outcome.

CONCLUSION

In conclusion, the healing of the greater and lesser tubercles is the major determinant of outcome following hemiarthroplasty for PHF repair.

Results of proximal humeral locked plating with supplemental suture fixation of rotator cuff

HYPOTHESIS

This study retrospectively reports the results of 81 patients with proximal humeral fractures that were treated operatively. We hypothesized that treatment of these injuries through a standardized technique of precountored locked plating and supplemental tension band suture fixation would result in improved clinical outcomes.

MATERIALS AND METHODS

All patients were evaluated with a minimum follow-up of 1 year. Clinical assessment was performed postoperatively with American Shoulder and Elbow Surgeons (ASES) scores and active range of motion measurements. Radiographic parameters assessed included Neer fracture pattern, fracture union, hardware failure, the presence of avascular necrosis, and medial calcar length and stability. Fractures were classified as 4-part in 14 (17%), 3-part in 41 (51%), and 2-part in 26 (32%).

RESULTS

The average ASES score was 80 (range, 27-100). The final range of motion averaged 131° of anterior elevation and 41° of external rotation. Fracture union was achieved in all patients, and there were no tuberosity failures. Complications included intraarticular screw penetration in 3 (3.7%) and avascular necrosis in 5 (6.2%).

DISCUSSION

Locked plating and supplemental tension band fixation can lead to fracture union and favorable outcomes. Restoration of the medial calcar and supplemental suture fixation may decrease the incidence of hardware-related complications.

The role of locking technology in the upper extremity

The technique of locked plating has been a major advance in Orthopaedic fracture surgery and has had an equal impact on the management of upper extremity fractures. The recognition of the role of vascularity and soft tissues in fracture healing was central to the research and development of newer plate designs that left minimal footprints on the surface of the bone. Subsequently, innovative locking technology has improved our ability to manage cases with extensive communition, inadequate bone stock, and peri-articular fractures. This paper will review the role of locking technology in the management of fractures of the upper extremity.

Tetracycline labeling as a measure of humeral head viability after 3- or 4-part proximal humerus fracture

HYPOTHESIS

Specifically located humeral head biopsies from three-part proximal humerus fractures taken at the time of hemiarthroplasty will show greater tetracycline labeling under fluorescent microscopy than those biopsies taken from four-part fractures. Additionally, biopsies from younger patients would show greater fluorescence than older patients.

MATERIAL AND METHODS

Nineteen consecutive adult patients (range 43-83 years) underwent hemiarthroplasty as definitive treatment for 20 displaced three- and four-part proximal humerus fractures after having received 500 mg of tetracycline hydrochloride orally every six hours for the immediate five preoperative days. Humeral head biopsies were taken from four pre-determined locations intraoperatively. The biopsies were prepared and analyzed with fluorescent microscopy.

RESULTS

All specimens in each biopsy location demonstrated fluorescence. There was no difference between the mean rank gray values for the four biopsy locations (p = 0.78 with the Friedman test). There was no difference between the mean rank gray values for the four biopsy locations when analyzed according to three-part vs four-part fracture (p > 0.05 with the Mann-Whitney test). There was an inverse relationship between age and fluorescence for the anterosuperior biopsy location (p = 0.033 with Spearman correlation).

DISCUSSION

Vascular supply is preserved in displaced three- and four-part proximal humerus fractures. With intact vascularity to the humeral head, head-preserving techniques utilizing stable, site-specific fixation and minimal dissection should be considered in the treatment of displaced three- and four-part proximal humerus fractures.

CONCLUSION

Vascular supply is preserved in displaced three- and four-part proximal humerus fractures, especially in younger patients in the anterosuperior aspect of the humeral head.

LEVEL OF EVIDENCE

Basic Science Study.

Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head

The purpose of this study was to review the outcome of patients with osteonecrosis of the humeral head, based on etiology and treatment with either hemiarthroplasty or total shoulder arthroplasty (TSA). Sixty-four shoulders, with an average age of 57 years, were evaluated at a mean of 4.8 years. Outcomes included L'Insalata and American Shoulder and Elbow Surgeons (ASES) scores, as well as range of motion (ROM). The overall ASES score was 67, average flexion was 127 degrees, and external rotation was 49 degrees. Outcomes did not differ based on etiology, but ROM was decreased with post-traumatic osteonecrosis. There was no difference in outcome or ROM between hemiarthroplasty and TSA. The complication rate was significantly higher with TSA (22%) than with hemiarthroplasty (8%). Achieving ROM in patients with post-traumatic osteonecrosis remains difficult. TSA was associated with a higher complication rate and decreased mobility and should be reserved for patients with stage V osteonecrosis.

Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency

BACKGROUND

Early designs of reverse shoulder arthroplasty components for the treatment of glenohumeral arthritis associated with severe rotator cuff deficiency in some cases have been associated with mechanical failure. The purpose of this study was to perform a prospective outcomes study of reverse shoulder arthroplasty performed with use of 5.0-mm peripheral locking screws for baseplate fixation and a lateralized center of rotation for the treatment of a rotator cuff deficiency.

METHODS

From February 2004 to March 2005, 112 patients (114 shoulders) were treated with a reverse shoulder arthroplasty as part of a United States Food and Drug Administration Investigational Device Exemption study. Ninety-four patients (ninety-six shoulders) were available for a minimum follow-up of two years. Of the ninety-six shoulders, thirty-seven had a primary rotator cuff deficiency, thirty-three had a previous rotator cuff operation, twenty-three had a previous arthroplasty, and three had a proximal humeral nonunion. The patients were prospectively followed clinically (the American Shoulder and Elbow Surgeons [ASES] score, the Simple Shoulder Test [SST], and self-reported satisfaction) and radiographically (mechanical failure, loosening, and notching). Patients were videotaped while performing a standard active range-of-motion protocol before and after treatment. These videos were then analyzed in a blinded fashion by three independent observers using a digital goniometer.

RESULTS

At two years, the average total ASES scores had improved from 30 preoperatively to 77.6; the average ASES pain scores, from 15 to 41.6; and the average SST scores, from 1.8 to 6.8 (p < 0.0001 for all). Blinded analysis of range of motion showed that average abduction improved from 61 degrees preoperatively to 109.5 degrees (p < 0.0001); average flexion, from 63.5 degrees to 118 degrees (p < 0.0001); and average external rotation, from 13.4 degrees to 28.2 degrees (p < 0.0001). The patients rated the outcome as excellent in fifty-three shoulders (55%), good in twenty-six (27%), satisfactory in eleven (12%), and unsatisfactory in six (6%). There was no evidence of mechanical failure of the baseplate or scapular notching in any of the patients. Six of the ninety-four patients in this study had a complication.

CONCLUSIONS

Recent advances in reverse shoulder arthroplasty have allowed for improvement in patient outcomes while minimizing early mechanical failure and scapular notching and decreasing the overall complication rate at short-term follow-up.

[Primary hemiarthroplasty in proximal humerus fractures]

The surgical treatment of complex proximal humerus fractures is still a great challenge. Not all fracture types can be successfully reconstructed. Indications for a primary joint replacement arise from critical fracture patterns and defined predictors of ischemia in the elderly (age >60 years). If good functional results are to be achieved a soft-tissue-preserving surgical technique, secure tuberosity attachment and accurate soft tissue balancing of the rotator cuff, correct restoration of height, retrotorsion and offset, and appropriate physiotherapy afterwards are essential. In multicentre studies in patients who had undergone primary hemoarthroplasty average Constant-Murlay Scores of 56.0-73.5 point were recorded. At follow-up, 79% of the patients reported only mild pain or none at all, and the ROM was acceptable (41.9% anteversion >90 degrees , 34.7% abduction >90 degrees ). Generally, subjective evaluations were much better than the objective results.The incidence of complications after humeral head replacement is still relatively high, whereas the 10-year survival rate of shoulder hemiarthroplasties has been found in a recent study to be 100%.

Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up

Significant discrepancy in the functional outcome of hemiarthroplasty for proximal humerus fractures has been reported with short or mid-term follow-up. This study reports the long-term results and rate of complications of shoulder arthroplasty in the treatment of proximal humerus fractures. The review comprised 57 patients (44 women, 13 men) who underwent hemiarthroplasty between 1976 and 1996 as treatment of a proximal humerus fracture and who had a minimum 5-year follow-up (mean, 10.3 years). The mean patient age was 66 years at the time of surgery (range, 23-89 years). According to a modified Neer result rating system, results were satisfactory in 27 patients and unsatisfactory in 30. The mean active elevation was 100 degrees (range, 20 degrees -180 degrees ) and external rotation was 30 degrees (range, 0 degrees -90 degrees ). At the most recent follow-up, 9 patients (16%) had moderate or severe pain and 2 required implant revision or removal. The study data suggest that patients undergoing arthroplasty as treatment of an acute fracture of the proximal humerus may achieve satisfactory long-term pain relief; however, the result for overall shoulder motion is less predictable. In view of these results, current indications, surgical technique, and postoperative treatment may need to be revisited.

Rehabilitation following reverse total shoulder arthroplasty

Reverse or inverse total shoulder arthroplasty (rTSA) is becoming a widely accepted surgical intervention. This procedure is specifically designed for the treatment of glenohumeral (GH) joint arthritis or complex fractures, when associated with irreparable rotator cuff (RC) damage or in the presence of RC arthropathy. Additionally, rTSA is an option for the revision of a previously failed conventional total shoulder arthroplasty (TSA) or hemiarthroplasty (HA) in the RC-deficient shoulder. The physical therapist, surgeon, and patient must take into consideration that the postoperative course for a patient following rTSA should be different than the rehabilitation following a traditional TSA. rTSA has only recently been approved by the Food and Drug Administration in the United States; however, nearly a 20-year history of its use exists in Europe. To date, we are aware of no peer-reviewed published descriptions of the postoperative rehabilitation for patients having undergone this procedure. The purpose of this paper is to review the indications for rTSA, focusing on underlying pathology, and to outline a rehabilitation protocol founded on basic science principles and our experience working with patients following rTSA.

Shoulder arthroplasty for traumatic avascular necrosis: predictors of outcome

Posttraumatic avascular humeral head necrosis may require salvage shoulder arthroplasty in symptomatic cases. We tested the hypothesis that associated tuberosity malunion negatively influences the final clinical outcome after shoulder arthroplasty. Thirty-eight patients with posttraumatic avascular necrosis of the humeral head were followed clinically and radiographically for a minimum of 5 years (mean, 8 years; range, 5-13 years). To quantify preoperative tuberosity malunion, two novel radiographic parameters were introduced: on the anteroposterior view, the greater tuberosity offset as a measurement of lateralization of the greater tuberosity; and on the axillary view, the posterior offset to quantify the degree of widening at the intertubercular groove. At last followup, the average Constant and Murley score had improved from 27 points preoperatively to 57 points postoperatively; shoulder range of motion had increased from 40 degrees abduction to 116 degrees, flexion from 45 degrees to 120 degrees, and external rotation from 15 degrees to 39 degrees. Functional improvements and pain relief were substantial. A significant correlation was found between greater tuberosity offset and posterior offset and final clinical outcome. Preoperative near anatomic tuberosity alignment was associated with good results. The greater tuberosity offset and posterior offset are useful and reliable radiographic predictors of outcome.

Reattachment of the tuberosities with cable wires and bone graft in hemiarthroplasties done for proximal humeral fractures with cable wire and bone graft: 58 patients with a 22-month minimum follow-up

OBJECTIVE

The stability of 2 fixation techniques for the tuberosities in patients with 3- or 4-part proximal humerus fractures treated with hemiarthroplasties was compared.

DESIGN

Retrospective review of a nonrandomized sequential series of patients.

SETTING

Level I university orthopaedic surgery department.

PATIENTS

A consecutive series of 58 patients (average age, 64 years) from 1990 to 1999 with 3- and 4-part fractures of the proximal humerus.

INTERVENTION

In group 1, 31 patients were treated with either a Neer or Aequalis shoulder prosthesis using nonabsorbable sutures and no bone graft for the reattachment of the tuberosities. In group 2, 27 patients were treated with either an Aequalis or Epoca shoulder prosthesis and a combination of cable fixation and bone grafting.

MAIN OUTCOME MEASUREMENTS

At follow-up (average, 32 months), radiographs were taken to confirm tuberosity fixation or degree of displacement or resorption. Functional outcome was assessed by the Constant-Murley Score.

RESULTS

Significantly more dislocated tuberosities were found radiographically in group 1 (10 of 13 in total, P = 0.011), and significantly more tuberosities were resorbed in group 1 (9 of 12 in total, P = 0.012). Significant differences in functional results among healed versus failed tuberosity fixation were observed for activity of daily living (P = 0.05), range of motion (P = 0.002), strength (P = 0.01), the total score (P = 0.008), and the passive rotation amplitude (P = 0.04).

CONCLUSION

In hemiarthroplasties for proximal humeral fractures, the reattachment of the tuberosities with cable wire and bone grafting gives consistently better radiographic and functional results than with suture fixation alone.

Reverse shoulder arthroplasty for the treatment of proximal humeral fractures

Proximal humeral fractures occurring in elderly patients often lead to significant functional disability. The outcome of nonoperative management is disappointing. Treatment with open reduction and internal fixation may result in osteonecrosis of the humeral head, and pain. Hemiarthroplasty is often associated with tuberosity nonunion and poor function. Reverse shoulder arthroplasty is an attractive alternative because of the ability of the prosthesis to compensate for tuberosity complications. Early studies have shown promise in using the prosthesis to treat these difficult patients. The next step will require prospective, randomized studies to determine which patient groups derive any benefit from reverse shoulder arthroscopy. The technology should be used judiciously.

Primary Joint Replacement in Proximal Humeral Fractures

The surgical treatment of proximal humeral fractures constitutes a great challenge. Not all fracture types can be successfully reconstructed. Indications for a primary joint replacement arise from critical fracture patterns and defined ischemia-predicting criteria in the elderly. Good functional results are received by a soft-tissue preserving surgical technique, a secure tuberosity attachment and accurate soft tissue balancing of the rotator cuff, a correct restoration of height, retrotorsion and offset, and an appropriate aftertreatment. Multicenter studies observed an averaged Constant Murlay Score of 56 to 73.5 points. 79% of the patients had no or only mild pain in the follow up, ROM was acceptable (41.9% Anteversion >90°, 34.7% Abduction >90°). Generally, subjective evaluations are much better than objective results. The incidence of complications after primary humeral head replacement is still relatively high, whereas the 10-year-survival-rate of shoulder hemiarthroplasties was found to be 100%, currently.

Effectiveness of replacement arthroplasty with calcar grafting and avoidance of greater tuberosity osteotomy for the treatment of humeral surgical neck nonunions

A retrospective review was conducted on 12 patients (mean age, 63 years) undergoing replacement arthroplasty with calcar grafting for humeral surgical neck nonunions. Patients were evaluated preoperatively for pain and range of motion and postoperatively by use of the American Shoulder and Elbow Surgeons and Constant scores. Indications included severe pain, disability, humeral head destruction, and inadequate bone stock. Nine patients were available for a mean of 69 months' follow-up. Eight underwent humeral head replacement, and one underwent total shoulder replacement. None required greater tuberosity osteotomy. Previously, open reduction-internal fixation had failed in 2 and closed reduction and percutaneous pinning had failed in 1. Calcar grafts were incorporated in 7 of 9 patients. Postoperative pain was absent in 7 and mild in 2. Mean active forward elevation improved by 64 degrees . Mean active external rotation improved by 45 degrees . Postoperatively, American Shoulder and Elbow Surgeons scores averaged 80 and Constant scores averaged 64. Replacement arthroplasty with calcar grafting is a reliable treatment option for surgical neck nonunions.

Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty

Our goal was to analyze the results of unconstrained shoulder replacement in a large series of sequelae of proximal humeral fractures in order to validate a previously described surgical classification. In a multicenter study, we retrospectively evaluated 203 patients with sequelae of proximal humeral fractures who were treated with a nonconstrained modular and adaptable prosthesis. The mean followup was 42 months (range, 24-96 months). We identified 137 impacted fractures with humeral head collapse or necrosis (Type 1 sequelae), 25 unreducible dislocations or fracture-dislocations (Type 2), 22 nonunions of the surgical neck (Type 3), and 19 severe tuberosity malunions (Type 4). Results of nonconstrained shoulder arthroplasty for the treatment of Type 1 and Type 2 sequelae were predictably good because no greater tuberosity osteotomy was performed. The distorted anatomy was accepted, and both the prosthesis and technique were modified accordingly. Total shoulder arthroplasty yielded better results than hemiarthroplasty. Patients with Type 3 or Type 4 sequelae had poor functional results with nonconstrained arthroplasty because greater tuberosity osteotomy was needed. This study validates our fracture sequelae classification. We no longer use unconstrained prostheses in Type 3 and Type 4 fracture sequelae and propose peg bone grafting or low-profile fracture prosthesis for patients with Type 3 sequelae and reverse arthroplasty for those with Type 4 sequelae.

LEVEL OF EVIDENCE

Prognostic study, level IV (case series). See Guidelines for Authors for a complete description of levels of evidence.

Rehabilitation following total shoulder arthroplasty

Total shoulder arthroplasty (TSA) is a standard operative treatment for a variety of disorders of the glenohumeral joint. Patients, who have continued shoulder pain and loss of function in the presence of advanced joint pathology, despite conservative management, are often managed by undergoing a TSA. The overall outcomes that are reported after surgical intervention are quite good and appear to be primarily determined by the underlying pathology and the tissue quality of the rotator cuff. The current Neer protocol for postoperative TSA rehabilitation is widely used and based on tradition and the basic science of soft tissue and bone healing. The purpose of this paper is to review the indications for TSA, focusing on the underlying pathologies, and to describe the variables that impact the rehabilitation program of individuals who have had a TSA. A postoperative TSA rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented.

The treatment of proximal humeral fractures with intramedullary titanium helix wire by 97 patients

INTRODUCTION

The displaced proximal humeral fracture continues to be a problem and remains the "unsolved fracture". Many guidelines for surgical treatment of different types of these fractures have been described. A conservative functional therapy is recommended as well as a closed or open reposition and internal fixation. Other authors prefer the primary prosthetic replacement of the displaced humeral head. The purpose of this article is to describe a minimal invasive technique--the intramedullary titanium helix wire--and to analyse results and specific problems of this method compared to other techniques.

MATERIALS AND METHODS

In a prospective study done over a period of 5 years from 1998 to 2002, 97 patients with two-, three- and four-part-fractures of the proximal humerus were treated with the intramedullary titanium helix wire and given follow-up clinical and radiological checks after 12 months. The functional outcome was evaluated with a 1-year follow-up in 95 of 97 patients.

RESULTS

Our 1-year results include: 41 very good, 24 good, 16 satisfactory, 14 poor (average 76 points Constant functional score, 30.7 points UCLA score).

CONCLUSION

The advantages of the method arising from the results lie in both the simple operation approach without nerve lesions or wound infections, and also in the indirect, intramedullary splinting of the fracture without damage to the surrounding soft parts, while iatrogenic necroses of the humeral head can be avoided.

A new prosthetic design for proximal humeral fractures: reconstructing the glenohumeral unit

A new shoulder prosthesis design for proximal humeral fractures has been developed. The rim of the articular component of this prosthesis has several holes to which the bone-tendon junction of the rotator cuff is fixed, to allow an anatomic reconstruction of the glenohumeral unit. The strength of the tuberosity fixation to this prosthesis is investigated in a cadaveric study. Artificial 4-part fractures were created in 18 human, fresh-frozen, paired shoulder joints with intact rotator cuffs. Two methods of tuberosity fixation were used in a matched-pair fashion. In group I the tuberosities were sutured to the rim of the prosthetic head, and in group II the tuberosities were circumferentially tension band-wired. Strength testing was performed on a material-testing machine, and displacement was recorded with an opto-electronic device. Both fixation methods proved to be equally reliable in the forces exerted during activities of daily living without significant displacement of the fracture fragments.

Shoulder arthroplasty for late sequelae of proximal humeral fractures

Twenty-eight patients with sequelae of proximal humeral fractures were treated with shoulder arthroplasty and were reviewed with a mean follow-up of 47 months. There were 8 malunions, 7 osteonecrosis, and 2 nonunions of the proximal humerus. Degenerative joint disease without any distortion of the tuberosities had developed in 11. We performed 8 total shoulder arthroplasties and 20 hemiarthroplasties. On the basis of the Neer criteria, the results were satisfactory in only 64%. Fifteen patients had superior migration of the implant. One patient had to be reoperated on because of deep infection. The prognosis was influenced positively by the integrity of the rotator cuff at surgery, whereas the need for greater tuberosity osteotomy worsened the final result. The data suggest that malunion of the greater tuberosity can be tolerated if it does not compromise acceptable positioning of the humeral component. However, if there is a malunion of the greater tuberosity with major displacement, an osteotomy must be performed, with unpredictable results.

Outcome of open reduction and internal fixation of surgical neck nonunions of the humerus

OBJECTIVE

The purpose of this study was to evaluate the results of open reduction and internal fixation of nonunions of the surgical neck of the humerus.

DESIGN

Retrospective review of patients who underwent operative treatment of a surgical neck of the humerus nonunion.

SETTING

Shoulder and elbow service at two university centers.

PATIENTS

Thirteen patients with a two-part nonunion of the surgical neck of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 12 months' follow-up were included. Patients with avascular necrosis, posttraumatic arthritis, severe humeral head bone loss, or a nonunion of one of the two tuberosities were excluded.

INTERVENTION

Open reduction and internal fixation with either a blade plate or a T-plate and autogenous bone graft.

MAIN OUTCOME MEASURES

Medical records, operative reports, physical examination, and preoperative and postoperative radiographs were reviewed. Outcome was assessed using Neer's criteria for the evaluation of total shoulder arthroplasty, visual analogue pain scale, range of motion, and ability to perform activities of daily living.RESULTS The results were excellent in 11 patients, satisfactory in 1 patient, and poor in 1 patient. The 11 nonunions in patients with excellent results healed within 6 months. The patient with the poor result initially had a persistent nonunion and required revision, open reduction and internal fixation, and bone grafting. This patient healed and went on to have an excellent result at final follow-up. All fractures were healed at the time of this study. Pain scores decreased from an average of 4.2 preoperatively to 1.2 postoperatively on a 5-point pain scale. Forward elevation in the scapular plane improved from 24 degrees preoperatively to 144 degrees postoperatively. All patients but one were able to attain overhead elevation. All patients were able to perform activities of daily living, such as dressing, bathing, combing hair, and performing perineal care, at final follow-up. Overall satisfaction increased from an average of 1.0 to 9.4 on a 10-point visual analogue scale.

CONCLUSIONS

Open reduction and internal fixation with autogenous bone graft results in excellent outcomes even in patients >65 years old and patients with significant medical problems. This treatment method offers predictable fracture healing and has a low complication rate.