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Baker HP, Gutbrod J, Cahill M, Shi L. Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges. Orthop Res Rev 2023; 15:129-137. [PMID: 37396822 PMCID: PMC10312335 DOI: 10.2147/orr.s340536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Joseph Gutbrod
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Michael Cahill
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Lewis Shi
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
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Warnhoff M, Jensen G, Lill H, Ellwein A. [Current trends in reverse fracture arthroplasty]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:690-698. [PMID: 35861875 DOI: 10.1007/s00113-022-01211-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.
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Affiliation(s)
- M Warnhoff
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland.
| | - G Jensen
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
| | - H Lill
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
| | - A Ellwein
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
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Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures. Injury 2021; 52:2285-2291. [PMID: 34148652 DOI: 10.1016/j.injury.2021.05.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures. PATIENTS AND METHODS Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value. RESULTS After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported. DISCUSSION Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.
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Uschok S, Herrmann S, Pauly S, Perka C, Greiner S. Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up. Arch Orthop Trauma Surg 2018; 138:1647-1652. [PMID: 30062455 DOI: 10.1007/s00402-018-3015-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living (ADL) and range of motion (ROM) of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Stephan Uschok
- Charité, Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sebastian Herrmann
- Helios Klinikum Emil von Behring, Walterhöferstrasse 11, 14169, Berlin, Germany
| | - Stephan Pauly
- Charité, Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Carsten Perka
- Charité, Universitaetsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan Greiner
- Sportopaedicum Regensburg, Hildegard-von-Bingen-Str. 1, 93053, Regensburg, Germany.
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Reverse shoulder arthroplasty: the role of physical therapy on the clinical outcome in the mid-term to long-term follow-up. Arch Orthop Trauma Surg 2018; 138:1347-1352. [PMID: 29916056 DOI: 10.1007/s00402-018-2977-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Reverse shoulder arthroplasty shifts the rotational center of the shoulder joint caudally and medially to restore shoulder function in a rotator cuff deficient shoulder. Despite promising results in early- and mid-term follow-up, long-term loss in shoulder function has been described in the literature. A lack of exercise in elderly patients may be one reason for this loss in function. This study examines the functional benefits of physical therapy in the mid-term to long-term follow-up regarding the subjective and objective shoulder function. MATERIALS AND METHODS Twenty patients with a mean age of 73 years were included in this series. The study was performed as a single-center, prospective study. Initial indications for reverse shoulder arthroplasty were cuff tear arthropathy, failed anatomical shoulder arthroplasty, and fracture sequelae. The patients were clinically examined at a mean follow-up of 62 months using the Constant score (CS) and the DASH score for the operated and the non-operated shoulder. They were reevaluated using the same scores following a standardized physical therapy program of 6 weeks' duration. RESULTS The mean CS as well as the mean age- and gender-adjusted CS of the affected shoulder improved significantly from 53.5 points to 59.3 points, and 72.7-80.8%, respectively. The subcategories activities of daily living and range of motion of the CS improved significantly, whereas no significant improvement was observed for the subcategories pain and strength. Evaluating the contralateral shoulder, no significant change was observed for the age- and gender-adjusted CS and the CS as well as its subcategories. We found no significant difference in the CS comparing the different etiologies prior to physical therapy. DISCUSSION Physical therapy plays an important role subsequent to reverse shoulder arthroplasty. It also has an effect in the mid-term to long-term follow-up regarding the range of motion as well as activities of daily living. However, physical therapy seems to have limited effect on the strength and the residual pain level. LEVEL OF EVIDENCE Level III.
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Heuberer PR, Brandl G, Pauzenberger L, Laky B, Kriegleder B, Anderl W. Radiological changes do not influence clinical mid-term outcome in stemless humeral head replacements with hollow screw fixation: a prospective radiological and clinical evaluation. BMC Musculoskelet Disord 2018; 19:28. [PMID: 29357861 PMCID: PMC5778649 DOI: 10.1186/s12891-018-1945-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/15/2018] [Indexed: 11/16/2022] Open
Abstract
Background Stemless shoulder arthroplasty is a fairly new concept. Clinical and radiological follow-up is essential to prove implant safety and concept. This prospective single-centre study was performed to evaluate the influence of radiological changes on clinical mid-term outcome following stemless humeral head replacement with hollow screw fixation. Methods Short- and mid-term radiological and clinical evaluations were performed in 73 consecutive shoulders treated mainly for idiopathic and posttraumatic osteoarthritis with stemless humeral head arthroplasty including 40 hemi- (HSA) and 33 total shoulder arthroplasties (TSA). Operating times of stemless implantations were compared to 110 stemmed anatomical shoulder prostheses. Appearances of humeral radiolucencies or radiological signs of osteolysis or stress shielding were assessed on standardized radiographs. Patients’ clinical outcome was evaluated using the Constant score and patients’ satisfaction was documented. Results Radiological changes, detected in 37.0%, did not affect clinical outcome. Constant scores significantly improved from baseline to short and mid-term follow-up (p < 0.001). The majority of patients (96.2%) were satisfied with the procedure. No loosening of the humeral head component was detected during a mean follow-up of 58 months. Operating times were significantly shorter with stemless compared to stemmed implants (p < 0.001). Conclusions Clinical mid-term outcome after stemless humeral head replacement was not affected by radiological changes. Trial registration The institutional review board (St. Vincent Hospital Vienna; 201212_EK01; date of issue: 11.12.2012) approved the study. The trial was registered at ClinicalTrials.gov (NCT02754024). Retrospective registration.
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Affiliation(s)
- Philipp R Heuberer
- St. Vincent Shoulder and Sports Clinic Vienna, Baumgasse 20A, 1030, Vienna, Austria.,Austrian Research group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria
| | - Georg Brandl
- St. Vincent Shoulder and Sports Clinic Vienna, Baumgasse 20A, 1030, Vienna, Austria
| | - Leo Pauzenberger
- St. Vincent Shoulder and Sports Clinic Vienna, Baumgasse 20A, 1030, Vienna, Austria
| | - Brenda Laky
- St. Vincent Shoulder and Sports Clinic Vienna, Baumgasse 20A, 1030, Vienna, Austria.,Austrian Research group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria
| | - Bernhard Kriegleder
- St. Vincent Shoulder and Sports Clinic Vienna, Baumgasse 20A, 1030, Vienna, Austria
| | - Werner Anderl
- St. Vincent Shoulder and Sports Clinic Vienna, Baumgasse 20A, 1030, Vienna, Austria. .,Austrian Research group for Regenerative and Orthopedic Medicine (AURROM), Vienna, Austria.
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Chen H, Ji X, Gao Y, Zhang L, Zhang Q, Liang X, Tang P. Comparison of intramedullary fibular allograft with locking compression plate versus shoulder hemi-arthroplasty for repair of osteoporotic four-part proximal humerus fracture: Consecutive, prospective, controlled, and comparative study. Orthop Traumatol Surg Res 2016; 102:287-92. [PMID: 26947731 DOI: 10.1016/j.otsr.2015.12.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 11/11/2015] [Accepted: 12/03/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the outcomes of intramedullary fibular allograft (IFA) with locking compression plates (LCPs) versus shoulder hemi-arthroplasty (HA) in osteoporotic four-part proximal humeral fracture (PHF). METHODS Between January 2010 and December 2012, totally 60 cases with osteoporotic four-part PHF were enrolled in this study and were randomly separated into IFA and LCPs group and HA group (n=30). Additionally, surgery indexes for patients in the two groups, such as Constant-Murley score (CMS), the Disability of Arm, Shoulder and Hand (DASH) score, individual subject evaluation of the outcomes, plain X-ray, and computer tomography (CT) scanning were evaluated and compared. RESULTS CMS, DASH score, activities of daily living (ADL), and range of motion (ROM) were statistically higher in the IFA and LCPs group than those in the HA group at the last follow-up, whereas the pain were obviously lower than that in the HA group. Besides, patients in the IFA and LCPs group had higher abduction, external rotation with elbow, strength, and satisfactory rating compared with HA group at the last follow-up. However, one case developed avascular necrosis (AVN), one case encountered screw perforation, and one case experienced varus displacement in the IFA and LCPs group, while there were 2, 4, and 2 cases suffered from superficial infection, shoulder stiffness, tuberosity migration in the HA group, respectively. CONCLUSION IFA with LCP have an advantage in functional outcomes than shoulder HA. LEVEL OF EVIDENCE Level II. Prospective cohort study.
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Affiliation(s)
- H Chen
- The Department of Orthopaedic, The General Hospital of People's Liberation Army (301 hospital), 28 Fuxing road, Beijing 100853, PR China
| | - X Ji
- The Department of Orthopaedic, The General Hospital of People's Liberation Army (301 hospital), 28 Fuxing road, Beijing 100853, PR China
| | - Y Gao
- The Department of Orthopaedic, The General Hospital of People's Liberation Army (301 hospital), 28 Fuxing road, Beijing 100853, PR China
| | - L Zhang
- The Department of Orthopedic, KuanCheng Hospital, KuanCheng, Hebei, PR China
| | - Q Zhang
- The Department of Orthopaedic, The General Hospital of People's Liberation Army (301 hospital), 28 Fuxing road, Beijing 100853, PR China
| | - X Liang
- The Department of Orthopaedic, The General Hospital of People's Liberation Army (301 hospital), 28 Fuxing road, Beijing 100853, PR China
| | - P Tang
- The Department of Orthopaedic, The General Hospital of People's Liberation Army (301 hospital), 28 Fuxing road, Beijing 100853, PR China.
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Shukla DR, McAnany S, Kim J, Overley S, Parsons BO. Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis. J Shoulder Elbow Surg 2016; 25:330-40. [PMID: 26644230 DOI: 10.1016/j.jse.2015.08.030] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND We performed a meta-analysis of studies with at least Level IV evidence to compare outcomes between hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures. METHODS Three electronic databases (PubMed, Cochrane, and EMBASE) were searched. The quality of each study was investigated, and data on radiographic and functional outcomes were extracted and analyzed. RESULTS The analysis included 1 Level I study, 1 Level II study, 3 Level III studies, and 2 Level IV studies. Reverse shoulder arthroplasty was more favorable than hemiarthroplasty in forward elevation (P < .001), abduction (P < .001), tuberosity healing (P = .002), Constant score (P < .001), American Shoulder and Elbow Surgeons score (P < .001), and Disabilities of the Arm, Shoulder and Hand score (P = .001). Only external rotation (P = .85) was not in favor of reverse shoulder arthroplasty. CONCLUSIONS The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication.
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Affiliation(s)
- Dave R Shukla
- Leni & Peter May Department of Orthopaedics, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Steven McAnany
- Leni & Peter May Department of Orthopaedics, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun Kim
- Leni & Peter May Department of Orthopaedics, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sam Overley
- Leni & Peter May Department of Orthopaedics, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bradford O Parsons
- Leni & Peter May Department of Orthopaedics, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Reverse shoulder arthroplasty for acute proximal humeral fractures in the geriatric patient: results, health-related quality of life and complication rates. INTERNATIONAL ORTHOPAEDICS 2016; 40:771-81. [PMID: 26780717 DOI: 10.1007/s00264-015-3085-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/17/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Reverse shoulder arthroplasty (RSA) in fractures is especially indicated in patients of advanced age, although the influence of age on functional outcomes, health-related quality of life (HRQoL) and complication rate is unknown. We hypothesized that complication rate would decrease in the geriatric population because of their reduced activity, improving the perceived HRQoL. METHODS Retrospective study of 42 patients with proximal humeral fractures treated with RSA, divided into two groups: <80 years (<80y)(n = 16) and ≥80 years (≥80y)(n = 26). The assessment tools used were radiological images (functional outcome) with the Constant-Murley score(CMS); disabilities of the arm, shoulder and hand (DASH) score; and HRQoL with the EQ-5D index. Mean follow-up time was 32.6 months. RESULTS Mean CMS adjusted for age and sex (R-CMS) was 68 % ± 29 %. Patients in the ≥80y group had a lower total CMS, 33 vs 64 (p = 0.027). Mean active range of motion at 24 months <80y/≥80y was: forward flexion: 126°/110°; abduction: 117°/105°; external rotation: 22°/20°; and internal rotation: L3/sacrum. Mean EQ-VAS was 74 ± 16 in the <80y group, and 63 ± 12.6 in the ≥80y group. Mean DASH was 29.5 ± 9.2. The EQ-5D "self-care" item in the >80y group was the most affected. The "pain/discomfort" item was lower for the two age groups than for the reference population. There were 9.5 % complications: one prosthesis dislocation, one periprosthetic fracture and two surgical wound haematoma. CONCLUSIONS Our results indicate that age is a critical factor for RSA success. Lower functional outcomes have been obtained in patients older than 80y, although the EQ-5D results in our sample were similar or even better than the referred population. LEVEL OF EVIDENCE Level III.
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Reconstruction techniques in comparison for reverse shoulder trauma prosthesis in the elderly: a follow-up between 2 and 4 years. Arch Orthop Trauma Surg 2015; 135:905-12. [PMID: 25907640 DOI: 10.1007/s00402-015-2221-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the clinical outcome of a bone graft technique called bCAT (bone Collar And Tie), in which the fractured humeral head is modelled into a collar shape versus puzzle piece reconstruction (PPR) in elderly patients with complex proximal humeral fractures. MATERIALS AND METHODS Between 2005 and 2011, we have performed 46 reverse shoulder prosthesis in patients with a mean age of 73.8 years (range 69-95) affected by shoulder complex fracture. A Delta CTA Depuy prosthesis was used in two patients, and a Lima SMR modular shoulder system in 44. To obtain a homogeneous group we compared the cases in which was used the same prosthesis with a similar follow-up. In a series of patients, we reconstructed tuberosities with the PPR technique (group A), while in another series we used the bCAT technique (group B). RESULTS The results were evaluated in 20 of group A and 20 of group B patients (mean clinical and radiological follow-up: 45.8 months). Average range of motion in group A was 111° anterior elevation, 90° abduction, 16° extrarotation and intrarotation till the sacral bone. The corresponding values in group B were 150°, 110°, 44° and L4. The mean absolute and age-adjusted Constant-Murley score were 55 and 67.85 %, respectively, in group A and 70.8 and 83.85 % in group B. Tuberosity resorption occurred in 40 % of group A versus 15 % in group B. CONCLUSION The PPR and the bCAT techniques promoted the healing and correct positioning of the tuberosities thereby resulting in good functioning of the residual cuff. The bCAT technique resulted in better clinical function particularly in abduction and extrarotation and in terms of radiological outcome of reverse prosthesis surgery.
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Alentorn-Geli E, Guirro P, Santana F, Torrens C. Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty. Arch Orthop Trauma Surg 2014; 134:1545-50. [PMID: 25138037 DOI: 10.1007/s00402-014-2074-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Fracture sequelae (FS) of the proximal humerus is a challenging scenario in shoulder surgery. Despite they have been traditionally treated with hemiarthroplasty (HA), the use of reverse shoulder arthroplasty (RSA) has been recently introduced. However, there are no studies comparing the results of HA and RSA in FS. The purpose of this study was to compare the functional and quality of life-related outcomes, and complications in the treatment of proximal humeral FS between HA and RSA. MATERIALS AND METHODS A therapeutic prospective non-randomized comparative study was conducted. All consecutive patients with diagnosis of FS after non-operative treatment of proximal humeral fractures and no previous shoulder surgery were considered for this study. A total of 32 patients (24 females, 8 males) with a mean (SD) age at the time of surgery of 80.1 (4.9) years were finally included: 12 in the HA group, and 20 in the RSA group. FS were treated with shoulder arthroplasty by the implantation of either HA or RSA. Constant score (total and specific items), quality of life (assessed through SF-36), and complications requiring revision surgery were compared between groups. RESULTS All parameters of the Constant score significantly improved in the postoperative compared to preoperative period when considering the entire sample. The RSA group demonstrated a higher improvement in total Constant score (p = 0.06) and Constant activity level (p = 0.02) compared to the HA group. The HA demonstrated a higher number of complications compared to the RSA (p = 0.05). There were no differences in SF-36 scores between both groups. CONCLUSIONS The shoulder arthroplasty is an effective treatment for FS with significant improvement in pain and function. The RSA may be a better option than HA for FS given the trend towards better total Constant score and a significantly lower number of complications requiring revision surgery. LEVEL OF EVIDENCE Therapeutic level II evidence.
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Affiliation(s)
- Eduard Alentorn-Geli
- Department of Orthopaedic Surgery and Traumatology, Parc de Salut Mar, Hospital del Mar & Hospital de l'Esperança, Universitat Autonoma de Barcelona (UAB), Passeig Marítim 25-29, 08003, Barcelona, Spain
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Abstract
Complex proximal humerus fractures with an avascular head fragment and unreconstructable fracture types represent indications for humeral head replacement. Special prosthetic designs allow modular anatomical restoration of the centre of rotation and alignment and stable fixation of the tuberosities. These play a key role with respect to the functional outcome and are often prone to complete or partial osteolysis with secondary rotator cuff deficiency. Because the operational procedure is technically demanding, attention must be paid to correct implantation. The functional results which can be expected are reliable with a moderate Constant score of 50 to 60 points and a low pain level. In elderly patients with poor bone quality and an associated increased tuberosity-related complication rate, a primary inverse prosthetic design has to be considered as a reasonable alternative. The overall revision rate is approximately 11 %.
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Fucentese SF, Sutter R, Wolfensperger F, Jost B, Gerber C. Large metaphyseal volume hemiprostheses for complex fractures of the proximal humerus. J Shoulder Elbow Surg 2014; 23:427-33. [PMID: 24012362 DOI: 10.1016/j.jse.2013.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 05/18/2013] [Accepted: 06/01/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Results of hemiarthroplasty after acute complex proximal humerus fractures are controversial. The main problem is the fixation and healing of the greater tuberosity (GT). To address this problem a hemiarthroplasty with a large metaphyseal volume was designed and introduced. METHODS Thirty hemiarthroplasties were implanted for acute, complex, proximal humeral fractures in 30 consecutive patients (average age: 63.3 years; range, 41-78). One patient was lost; 2 patients could only be interviewed telefonically. Two patients had to be revised because of secondary displacement of the GT within the first 2 postoperative years. The remaining 25 patients were assessed clinically, radiographically, and with computer tomography (CT) imaging after a mean of 25 months (range, 24-29). RESULTS Greater tuberosity healed in situ in 23 patients. In 12 cases, CT documented severe resorption of GT without displacement of a measurable bone fragment and an intact clinical cuff function with a radiographically preserved acromio-humeral distance. The mean Constant score was 59 points (range, 26-81), the mean relative Constant score 75% (range, 31-100). The mean anterior elevation was 117° (range, 45-160). The mean subjective shoulder value was 70% (range, 25-98). In 4 cases (14%), tuberosity dislocation occurred which was associated with an increase of fatty infiltration and poor result. CONCLUSION The 2-year results with a large metaphyseal volume fracture-prosthesis showed good to excellent results, with a failure rate of 14%. Substantial resorption of the greater tuberosity was frequent, but was not associated with functional incompetence of the rotator cuff. The overall results obtained justify its continued use.
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Affiliation(s)
- Sandro F Fucentese
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zürich, Switzerland.
| | - Reto Sutter
- Department of Radiology, University of Zurich, Balgrist University Hospital, Zürich, Switzerland
| | - Fabian Wolfensperger
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zürich, Switzerland
| | - Bernhard Jost
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, University of Zurich, Balgrist University Hospital, Zürich, Switzerland
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Tepass A, Rolauffs B, Weise K, Bahrs SD, Dietz K, Bahrs C. Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009. Patient Saf Surg 2013; 7:34. [PMID: 24268107 PMCID: PMC4176190 DOI: 10.1186/1754-9493-7-34] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 11/05/2013] [Indexed: 12/16/2022] Open
Abstract
Background The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns. Methods The databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test. Results Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)]. The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores. Discussion Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.
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Affiliation(s)
- Alexander Tepass
- Department of Radiology, Eberhard-Karls University, Tübingen, Germany.
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Hromádka R, Kuběna AA, Smíd M, Popelka S. Medial calcar of proximal humeral fracture as landmark in restoration of humeral length in case of hemiarthroplasty. Surg Radiol Anat 2013; 36:473-9. [PMID: 23942612 DOI: 10.1007/s00276-013-1184-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 08/02/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Several methods to restore the appropriate length of the humerus in the case of proximal humeral fractures treated by hemiarthroplasty have been previously published. Our study evaluates the possibility of using the medial calcar of humerus for humeral length reconstruction not based on preoperative planning. METHODS Preparations of 320 dry humeral bones were used for the purpose of the study. Points of interest were marked on each bone: the most proximal point of the humeral head, the crest of greater tuberosity, diameters of the head, the anatomical and surgical necks. Proximal parts of bones were then scanned from two angles with a digital camera and all measurements were performed on calibrated photographs. We compared accuracy in humeral length reconstruction using insertion of the pectoralis major and the area of medial calcar where usually a fracture develops. RESULTS The distance between the top part of the humeral head and the insertion of pectoralis major was 54.1 ± 6.0 mm. The distance between the lateral margin of the anatomical neck and the medial calcar was 51.4 ± 4.3 mm. We compared these data with diameters of the humeral head. CONCLUSIONS The site of the fracture can be used for the reconstruction of the humeral length with greater accuracy than area of the pectoralis major insertion. We suggest that to obtain the final distance between the lateral margin of the artificial head and medial calcar of the fracture 2-3 mm should be added to the diameter of the head.
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Affiliation(s)
- Rastislav Hromádka
- 1st Orthopaedic Clinic, 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic,
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Brorson S, Rasmussen JV, Olsen BS, Frich LH, Jensen SL, Hróbjartsson A. Reverse shoulder arthroplasty in acute fractures of the proximal humerus: A systematic review. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2013; 7:70-8. [PMID: 23960366 PMCID: PMC3743034 DOI: 10.4103/0973-6042.114225] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The indications for surgical intervention in complex fractures of the proximal humerus are disputed. In elderly patients with poor bone stock it may be impossible to obtain satisfactory fixation of the tuberosities to a hemiarthroplasty (HA). In such cases primary insertion of a reverse shoulder arthroplasty (RSA) has been suggested. We aimed to review clinical studies reporting benefits and harms of RSA in acute fractures. A systematic review. We included 18 studies containing 430 RSA in acute fractures. We found no randomized clinical trials. Four studies compared outcome after RSA with a historical control group of HA. The median constant score was 58 (range 44-68) which is comparable to previous reviews of HA in 4-part fractures. Complications included dislocation, infection, hematoma, instability, neurological injury, reflex sympathetic dystrophy, intraoperative fractures, periprosthetic fractures, and baseplate failure. Scapular notching was reported in 11 studies with a median value of 25% (range 0-94). Heterogeneity of study designs and lack of primary data precluded statistical pooling of data. No high quality evidence was identified. Based on the available evidence the use of RSA in acute fractures is questionable. The complication rate was high and the clinical implications of long term scapular notching are worrying. Randomized studies with long term follow up using the latest techniques of tubercular reinsertion in RSA toward HA should be encouraged.
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Affiliation(s)
- Stig Brorson
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark
| | - Jeppe V. Rasmussen
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark
| | - Bo S. Olsen
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark
| | - Lars H. Frich
- Department of Orthopaedic Surgery, Odense University Hospital, Rigshospitalet, Denmark
| | - Steen L. Jensen
- Department of Orthopaedic Surgery, Aalborg University Hospital, Rigshospitalet, Denmark
| | - Asbjørn Hróbjartsson
- Department of Orthopaedic Surgery, The Nordic Cochrane Centre, Rigshospitalet, Denmark
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Evaluation and management of proximal humerus fractures. Adv Orthop 2012; 2012:861598. [PMID: 23316376 PMCID: PMC3535990 DOI: 10.1155/2012/861598] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 11/12/2012] [Accepted: 11/12/2012] [Indexed: 02/06/2023] Open
Abstract
Proximal humerus fractures are common injuries, especially among older osteoporotic women. Restoration of function requires a thorough understanding of the neurovascular, musculotendinous, and bony anatomy. This paper addresses the relevant anatomy and highlights various management options, including indication for arthroplasty. In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. In the case of displaced fractures, when surgical intervention may be pursued, numerous constructs have been investigated. Of these, the proximal humerus locking plate is the most widely used. Arthroplasty is generally reserved for comminuted 4-part fractures, head-split fractures, or fractures with significant underlying arthritic changes. Reverse total shoulder arthroplasty is reserved for patients with a deficient rotator cuff, or highly comminuted tuberosities.
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Boons HW, Goosen JH, van Grinsven S, van Susante JL, van Loon CJ. Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial. Clin Orthop Relat Res 2012; 470:3483-91. [PMID: 22895694 PMCID: PMC3492647 DOI: 10.1007/s11999-012-2531-0] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 07/31/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Four-part fractures of the proximal humerus account for 3% of all humeral fractures and are regarded as the most difficult fractures to treat in the elderly. Various authors recommend nonoperative treatment or hemiarthroplasty, but the literature is unclear regarding which provides better quality of life and function. QUESTIONS/PURPOSES We therefore performed a randomized controlled trial to compare (1) function, (2) strength, and (3) pain and disability in patients 65 years and older with four-part humeral fractures treated either nonoperatively or with hemiarthroplasty. METHODS We randomly allocated 50 patients to one of the two approaches. There were no differences in patient demographics between the two groups. The Constant-Murley score was the primary outcome measure. Secondary outcome measures were the Simple Shoulder Test, abduction strength test as measured by a myometer, and VAS scores for pain and disability. All patients were assessed at 12 months. RESULTS We found no between-group differences in Constant-Murley and Simple Shoulder Test scores at 3- and 12-months followup. Abduction strength was better at 3 and 12 months in the nonoperatively treated group although the nonoperatively treated patients experienced more pain at 3 months; this difference could not be detected after 12 months. CONCLUSIONS We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment. LEVEL OF EVIDENCE Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Harm W. Boons
- Department of Orthopaedics, Elkerliek Hospital, Helmond, The Netherlands
| | - Jon H. Goosen
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands
| | - Susan van Grinsven
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands
| | - Job L. van Susante
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands
| | - Corné J. van Loon
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA Arnhem, The Netherlands
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Berth A, Pap G. Stemless shoulder prosthesis versus conventional anatomic shoulder prosthesis in patients with osteoarthritis: a comparison of the functional outcome after a minimum of two years follow-up. J Orthop Traumatol 2012; 14:31-7. [PMID: 23138538 PMCID: PMC3586071 DOI: 10.1007/s10195-012-0216-9] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 10/21/2012] [Indexed: 01/01/2023] Open
Abstract
Background The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only a few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant in comparison with a standard anatomic stemmed shoulder prosthesis. Materials and methods The Constant score, the DASH score, the active range of motion (abduction, anteversion, external rotation), and the radiological results were examined in 82 patients with primary osteoarthritis of the shoulder treated with either the Total Evolutive Shoulder System® (Biomed, France) stemless shoulder prosthesis or the Affinis® (Mathys, Switzerland) stemmed shoulder prosthesis to detect possible differences in the functional outcome and to evaluate radiological properties of the implants. Patients were examined before and 32 ± 4 months after surgery. Results There was no significant difference in the Constant scores of the groups treated with the stemless shoulder prosthesis (65.0 ± 11.0 points) and the stemmed shoulder prosthesis (73.2 ± 11.3 points; P = 0.162). The estimated blood loss (P = 0.026) and the mean operative time (P = 0.002) were significantly lower in the group with the stemless shoulder prosthesis. Conclusions The use of the stemless shoulder prosthesis yielded good results which, in a mid-term follow-up, were comparable with those provided by a standard anatomic shoulder prosthesis. Further investigations are needed regarding the long-term performance of this prosthesis.
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Affiliation(s)
- Alexander Berth
- Department of Orthopaedics, Otto-von-Guericke-University, 39120 Magdeburg, Germany.
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Berth A, Pap G, Lohmann C. Indikationsspezifische mittelfristige Ergebnisse der anatomischen Kurzschaft-Schulterprothese. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s11678-012-0162-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Relationship of cortical thickness of the proximal humerus and pullout strength of a locked plate and screw construct. J Orthop Trauma 2012; 26:222-5. [PMID: 22207205 DOI: 10.1097/bot.0b013e31822421f7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND No study to date has evaluated cortical thickness as it relates to locking plate failure or screw pullout in the proximal humerus. The purpose of this study is to determine the relationship between proximal humerus cortical thickness and locked plate hardware failure in a cadaveric proximal humerus fracture model. METHODS Twelve humerus specimens were placed into two groups based on the proximal humerus cortical thickness on an anteroposterior radiograph: less than 4 mm and greater than 4 mm. The specimens were plated with a six-hole proximal humerus locking plate and a 15-mm resection osteotomy at the surgical neck was performed. The specimens were tested in a materials testing machine at a displacement of 5 mm/min to failure. RESULTS Load at failure, stiffness, maximum load, failure, and fracture gap closure were all statistically similar (P > 0.05) between the groups. CONCLUSION Our biomechanical study used modern locked plate-screw construct fixation of a simulated two-part proximal humerus fracture. The mechanical strength was unaffected based on a threshold combined proximal humerus cortical thickness of 4 mm.
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Long term functional outcome following reverse shoulder arthroplasty in the elderly. Orthop Traumatol Surg Res 2011; 97:583-9. [PMID: 21917540 DOI: 10.1016/j.otsr.2011.03.025] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/13/2011] [Accepted: 03/21/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study is to analyze the long-term results and possible complications of the Grammont reverse shoulder prosthesis in the management of recent trauma in the elderly patient. PATIENTS AND METHODS Two male and 33 female patients of mean age 75 years (range, 58 to 92), operated on for 24 fractures and eleven facture-dislocations, involving the right side in 11 cases and the left side in 24 cases, were included in a retrospective study and were clinically and radiographically evaluated at a mean follow-up ranging from 1 to 17 years. RESULTS Eight complications occurred in eight patients (23%): two complex regional pain syndromes, four dislocations, one deep infection and one aseptic loosening of the metaglene. Six patients (17%) had to be reoperated on, without prosthetic replacement in four cases and with revision of their shoulder implant in two. The mean Constant score decreased from 55 to 53 between one postoperative year and last follow-up since patients complained of increased pain and strength loss. This score was 69% of that of the contralateral shoulder. The adjusted Constant score was 68%. Only 58% of the patients were "satisfied" or "very satisfied" with the treatment due to limited shoulder rotations thus preventing proper eating, dressing and body hygiene habits when injury involved the dominant side. Two cases of complete lucent lines surrounding the glenoid component were observed at four and eight postoperative years respectively, a stable inferior bony spur was noted in 14 cases at a mean follow-up of 2.5 years with no functional effects, 20 cases of scapular notching having occurred within two-year follow-up were identified, 10 of which associated with bone resorption and medial proximal humeral lucent lines at the bone-cement interface. The extent of scapular notching progressed with the length of follow-up. Forty-nine percent of the radiographic images were considered abnormal and appeared within seven-year follow-up in 60% of the cases. Clinical and radiographic data comparison revealed a decrease in the Constant score regarding pain, activity, strength and active elevation when scapular notching was associated with abnormal humeral radiographic images. DISCUSSION Despite one single case of aseptic loosening of the metaglene at 12-year follow-up, the results of our series are clinically disappointing and radiographically worrying associated with a substantial rate of complications and reopperations. The long-term functional outcome is far from being identical to the pre-trauma clinical status with a potential evolution toward loss of autonomy when the dominant side is affected. New prosthetic design characteristics and surgical technique improvements should be implemented to improve shoulder adduction but also rotations while preventing the occurrence of scapular notching. In the light of these results, we cannot validate the concept of primary reverse shoulder arthroplasty in the management of recent trauma of the proximal humerus.
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Herrmann S, König C, Heller M, Perka C, Greiner S. Reverse shoulder arthroplasty leads to significant biomechanical changes in the remaining rotator cuff. J Orthop Surg Res 2011; 6:42. [PMID: 21846390 PMCID: PMC3184075 DOI: 10.1186/1749-799x-6-42] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 08/16/2011] [Indexed: 11/10/2022] Open
Abstract
Objective After reverse shoulder arthroplasty (RSA) external and internal rotation will often remain restricted. A postoperative alteration of the biomechanics in the remaining cuff is discussed as a contributing factor to these functional deficits. Methods In this study, muscle moment arms as well as origin-to-insertion distance (OID) were calculated using three-dimensional models of the shoulder derived from CT scans of seven cadaveric specimens. Results Moment arms for humeral rotation are significantly smaller for the cranial segments of SSC and all segments of TMIN in abduction angles of 30 degrees and above (p ≤ 0.05). Abduction moment arms were significantly decreased for all segments (p ≤ 0.002). OID was significantly smaller for all muscles at the 15 degree position (p ≤ 0.005), apart from the cranial SSC segment. Conclusions Reduced rotational moment arms in conjunction with the decrease of OID may be a possible explanation for the clinically observed impaired external and internal rotation.
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Affiliation(s)
- Sebastian Herrmann
- Center for Musculosceletal Surgery, Charité-Universitätsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany.
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Babhulkar A, Shyam AK, Sancheti PK, Shah K, Rocha S. Hemiarthroplasty for comminuted proximal humeral fractures. J Orthop Surg (Hong Kong) 2011; 19:194-9. [PMID: 21857044 DOI: 10.1177/230949901101900213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate early functional outcomes of hemiarthroplasty for 3- or 4-part proximal humeral fractures. METHODS 16 men and 11 women aged 27 to 83 (mean, 56) years underwent hemiarthroplasty for comminuted 3-part (n=13) or 4-part (n=14) proximal humeral fractures. All the patients reported normal shoulder function prior to injury. The range of shoulder motion and muscle power were evaluated, as were subjective pain and satisfaction (using the UCLA scoring system). RESULTS At the final follow-up, the mean maximum abduction was 111º (SD, 47º; range, 30º-180º), and the mean maximum forward flexion was 143º (SD, 41º; range, 45º-180º). All patients had radiographic union of the tuberosities. The mean UCLA score was 28; 21 patients attained good-to-excellent scores (≥27), whereas 6 attained lower (fair-to-poor) scores. The mean UCLA score was higher in patients aged <60 (n=13) than those who were older (n=14) [30 vs. 26, p=0.008] and in patients operated after 7 days (n=6) than those operated before 7 days (n=21) [32 vs. 27, p=0.02], but did not differ significantly in terms of gender and fracture type and side. Patient age and gender, fracture type, and injury-to-surgery interval did not have a significant impact on maximum forward flexion and abduction. CONCLUSION Early functional outcomes of hemiarthroplasty for comminuted proximal humeral fractures is good in medically fit and cooperative patients.
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Affiliation(s)
- Ashish Babhulkar
- Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India
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Farng E, Zingmond D, Krenek L, Soohoo NF. Factors predicting complication rates after primary shoulder arthroplasty. J Shoulder Elbow Surg 2011; 20:557-63. [PMID: 21324715 DOI: 10.1016/j.jse.2010.11.005] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 10/26/2010] [Accepted: 11/01/2010] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Shoulder arthroplasty is an effective treatment for arthritic conditions and intraarticular fractures of the proximal humerus. Treatment options include total and hemiarthroplasty of the shoulder. They hypothesis of this study was that a mandatory statewide discharge database could identify the epidemiology of primary shoulder arthroplasty, 90 day complication rates, implant survival rates, and patient and hospital characteristics associated with complications. MATERIALS AND METHODS We identified patients undergoing primary total shoulder replacement and hemiarthroplasty between 1995 and 2005. We report rates of complications within 90 days of surgery and performed survival analysis using revision surgery as the endpoint. Logistic and proportional hazard regression models were used to estimate the effect of patient and provider factors in predicting the rates of adverse outcomes. RESULTS During the study period, 15,288 patients underwent shoulder arthroplasty. Patients undergoing total shoulder arthroplasty and hemiarthroplasty had no statistically significant difference in the aggregate risk of 90-day complications or the risk of implant failure within the study period. Fracture patients were shown to have a higher risk of short-term complications (odds ratio, 3.2; P < .001). Implant failure rates were lower in patients with fracture, rheumatoid arthritis, increased comorbidity, and advanced age. CONCLUSION This study reports similar rates of short-term complications and implant failure in patients undergoing total or hemiarthroplasty, an overall mortality rate of 1.3%, and a pulmonary embolism rate of 0.6%. The findings of our study indicate that the risk of short-term complications is highest in patients undergoing total or hemiarthroplasty for a fracture compared with nonfracture indications. Our results also indicate that longer-term, implant survival is largely driven by factors associated with increased activity, such as age. In patients undergoing surgery for arthritis of the shoulder, we found no difference in implant survival rates between total and hemiarthroplasty of the shoulder.
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Affiliation(s)
- Eugene Farng
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
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Abdelhady AM. Shoulder arthroplasty as a treatment for sequelae of proximal humeral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2010. [DOI: 10.1007/s00590-010-0630-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Drake GN, O'Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res 2010; 468:1526-33. [PMID: 20049573 PMCID: PMC2865601 DOI: 10.1007/s11999-009-1188-9] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reverse total shoulder arthroplasty (RTSA) was introduced to treat rotator cuff tear arthropathy but is now used to treat a variety of problems. Although its use has expanded substantially since the FDA's approval in 2004, the appropriateness in patients with rotator cuff disease is unclear. QUESTIONS/PURPOSES We review the use of RTSA in patients with rotator cuff disease to (1) describe classification of rotator cuff tear reparability and the concept of a balanced shoulder; (2) explore the theory behind RTSA design relative to rotator cuff arthropathy; (3) discuss the indications and contraindications for RTSA; and (4) review published outcomes of RTSA for rotator cuff arthropathy. METHODS We performed a selective review of the literature on the use of RTSA in the treatment of rotator cuff disease. RESULTS Modern RTSA designs restore deltoid tension and a functional fulcrum to the rotator cuff deficient shoulder, which allows recovery of active shoulder elevation and effectively restores function in short- and medium-term followup studies. CONCLUSIONS In short-term followup the RTSA relieves symptoms and restores function for patients with cuff tear arthropathy and irreparable rotator cuff tears with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA. CLINICAL RELEVANCE For properly selected patients who have symptomatic and disabling rotator cuff deficiency, RTSA can result in life-changing improvements in pain, motion, function, and patient satisfaction. LEVEL OF EVIDENCE Level V therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gregory N Drake
- Core Orthopedics and Sports Medicine, 555 Biesterfield Road, Elk Grove Village, IL 60007, USA.
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Gorthi V, Moon YL, Jo SH, Sohn HM, Ha SH. Life-threatening posterior circumflex humeral artery injury secondary to fracture-dislocation of the proximal humerus. Orthopedics 2010; 33. [PMID: 20349876 DOI: 10.3928/01477447-20100129-29] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Proximal humeral fractures account for 4% to 5% of all fractures, and most of these are minimally displaced and less prone to neurovascular injuries. This article presents a case of a 65-year-old man who injured the posterior circumflex humeral artery following a fracture dislocation of the proximal humerus leading to a life-threatening hemorrhagic complication during surgical fixation of the dislocated proximal humeral fracture. Preoperative vital signs were normal. Using the deltopectoral approach, the fracture site was exposed and the dislocated head was extracted. Blood pooled and overflowed the cavity at a brisk pace. Blood pressure dropped from 130/70 mm Hg to 90/45 mm Hg, and preoperative follow-up hemoglobin dropped to 4.8 g/dL. The axillary artery was explored and a ruptured posterior humeral circumflex artery was observed that was later ligated. In view of the damage to 1 of the circumflex humeral branches, primary hemiarthroplasty was performed. This article highlights the possibility of encountering life-threatening vascular injuries in highly displaced or dislocated 4-part proximal humeral fractures and the significance of obtaining the angiographic studies early in the course of management in such cases.
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Affiliation(s)
- Venkat Gorthi
- Department of Orthopedics, Chosun University Hospital, Gwangju, South Korea
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