[Indication for primary fracture prosthesis of the shoulder]

Outcomes and revision rates of primary vs. secondary reverse total shoulder arthroplasty for proximal humeral fractures

Background

Reverse total shoulder arthroplasty (RSA) is a standard treatment for proximal humeral fractures (PHF) and its sequelae. In this study we analyzed the clinical outcomes of primary vs. secondary RSA for displaced PHF in elderly patients.

Methods

We retrospectively reviewed 68 cases of primary or secondary RSA for displaced PHF. For 51 patients (28 primary RSA, 23 secondary RSA), a minimum 12-month follow-up with clinical and radiological assessment was available. Clinical assessment comprised joint active range of motion, DASH, Constant–Murley Score (CMS), Subjective Shoulder Value, and Visual Analog Scale for pain. Outcomes and complications of patients with primary RSA were compared with those of patients with secondary RSA.

Results

Follow-up data were available for 45 women and six men with a mean age of 73 years (range, 59–87) at the time of implantation. In 28 cases, primary RSA was performed; in 23 cases, RSA was performed as a revision procedure for fracture sequelae after failed plating, nailing, or hemiarthroplasty. The mean age- and gender-related CMS was 82.2 ± 34.2% (raw mean CMS: 46.8 ± 19.6 points). Among nine of the 51 patients with follow-up data (17.6%), ten complications occurred with six surgical revisions. Primary RSA (n = 28) resulted in better clinical shoulder function compared with secondary RSA (n = 23). Significantly more complications and revision surgeries were observed following secondary than primary RSA (p = 0.013).

Conclusion

In this study, primary RSA for displaced PHF in the elderly was associated with better clinical function and lower complication and revision rates than secondary RSA. Predictive parameters for failure of humeral head-preserving fracture fixation and anatomic hemiarthroplasty should be carefully evaluated. Primary RSA should be considered when surgical treatment of PHF is indicated in elderly patients.

[Periprosthetic humeral fractures: Strategies and techniques for osteosynthesis]

The prevalence of periprosthetic humeral fractures (PHF) is currently low and accounts for 0.6-2.4%. Due to an increase in the rate of primary implantations a quantitative increase of PHF is to be expected in the near future. The majority of PHF occur intraoperatively during implantation with an increased risk for cementless stems and when performing total arthroplasty. Additional risk factors are in particular female gender and the severity of comorbidities. In contrast, postoperative PHF mostly due to low-energy falls, have a prevalence between 0.6% and 0.9% and are significantly less common. The prognosis and functional outcome following revision by open reduction internal fixation (ORIF) essentially depend on a thorough assessment of the indications for revision surgery, the operative treatment and the pretraumatic functional condition of the affected shoulder. In the armamentarium of periprosthetic ORIF of the humerus cerclage systems and locking implants as well as a combination of both play a central role. In comminuted fractures with extensive defect zones, severely thinned cortex or extensive osteolysis a biological augmentation of the ORIF should be considered. In this context when the indications are correctly interpreted, especially in the case of a stable anchored stem, various groups have reported that a high bony union rate can be achieved. As the treatment of PHF is complex it should be performed in dedicated centers in order to adequately address potential comorbidities, especially in the elderly population.

Additional calcar support using a blade device reduces secondary varus displacement following reconstruction of the proximal humerus: a prospective study

Background

Locking plate fixation of displaced fractures of the proximal humerus is still accompanied by a distinct complication rate, especially in case of osteoporotic bone, short-segment fracture length and comminution of the medial calcar. Secondary loss of reduction leading to varus deformity and screw cutout most frequently lead to surgical revision. The aim of the present study was to evaluate the clinical and radiological outcome of a recently developed polyaxial locking plate that allows for the additional placement of a helical blade device, aiming for support of the medial calcar.

Methods

In this prospective study, 17 patients with a mean age of 63.0 ± 16.0 years suffering from displaced fractures of the proximal humerus (Neer type two-, three- and four-part) were enrolled. All patients were surgically treated using a polyaxial locking plate with additional blade device (group PAB, n = 12) or without blade device (group PA, n = 5). Functional outcome was recorded using the Munich Shoulder Questionnaire allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), the Disability of the Arm, Shoulder and Hand (DASH score) and the Constant Score. Radiological outcome was assessed by analyzing standardized true anterior–posterior and outlet-view radiographs with respect to radiographic evidence of secondary varus displacement, cutout of screws and hardware failure. Results were compared to an age-, gender- and fracture type-matched collective treated by monoaxial locking plate fixation (group MA, n = 15).

Results

The mean follow-up was 12.4 ± 2.9 months after surgery. There were no statistical significant differences in clinical outcome in all three groups. Group MA and group PA revealed significant secondary varus displacement in comparison to group PAB at the final follow-up compared to postoperative analysis (p < 0.001). The distance between the blade and the articular surface showed no significant increase in group PAB at the final follow-up compared to postoperative analysis. Not-implant-related complications were seen in one and implant-related complications were seen in two patients in group PAB.

Conclusions

Polyaxial locking plate fixation with a blade device to restore medial cortical support reduces the risk of secondary varus displacement even in proximal humeral fractures of the elderly in comparison to monoaxial and polyaxial locking plate fixation without blade insertion.