Cementless anatomical prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: cadaver study and prospective clinical study with minimum 2 years followup

Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review

BACKGROUND

Proximal humeral fractures are difficult injuries to treat and obtain satisfactory outcomes. For those treated with arthroplasty, humeral fracture stems have been popular due to better ability for reduction and fixation of tuberosities. This study aims to investigate the outcomes of fracture stems in shoulder arthroplasty for proximal humeral fracture and the comparison of outcomes between fracture vs. nonfracture stems.

METHODS

A meta-analysis was conducted with a multidatabase search (PubMed, OVID, EMBASE, Medline) according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines on May 19, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed.

FINDINGS

Eleven studies were included for analysis, including 383 hemiarthroplasties (HA) (294 fracture stems, 89 nonfracture stems) and 358 reverse total shoulder arthroplasties (RTSA) (309 fracture stems, 49 nonfracture stems). At the final follow-up, meta-analysis shows favorable overall ASES score in all fracture stem prosthesis (mean = 74.0, 95% confidence interval [CI]: 69.3-78.7), Constant-Murley score (mean = 67.2, 95% CI: 61.6-72.8), external rotation (mean difference [MD] = 7°, 95% CI: 3°-10°, P < .001), and forward flexion (MD = 17°, 95% CI: 10°-25°, P < .001). Pooled proportion (PP) of greater tuberosity healing (PP = 0.786, 95% CI: 0.686-0.886) was high, whereas all-cause revisions (PP = 0.034, 95% CI: 0.018-0.061) remained low. With the exception of RTSA scapular notching (PP = 0.109, 95% CI: 0.020-0.343), other complication metrics had PP of ≤0.023. In the 4 studies comparing fracture (138 HA, 54 RTSA) vs. nonfracture stems (89 HA, 49 RTSA), fracture stems had statistically significant better American Shoulder and Elbow Surgeons scores (MD = 14.29, 95% CI: 8.18-20.41, P < .001), external rotation (MD = 6°, 95% CI: 2°-9°, P = .003), forward flexion (MD = 16°, 95% CI: 7°-24°, P < .001), and greater tuberosity healing (odds ratio = 2.20, 95% CI: 1.28-3.77, P = .004). There was no statistically significant difference in complications.

CONCLUSION

Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. The use of fracture stems is also associated with greater chance of tuberosity healing compared with nonfracture stems. There is increasing evidence to suggest the superiority of fracture stems over nonfracture stems in clinical outcomes, while maintaining similar complication rates.

Early outcomes of locked noncemented stems for the management of proximal humeral fractures: a comparative study

BACKGROUND

Proximal humeral fractures are common and a major concern in public health resources utilization. There is an increase in the use of reverse total shoulder arthroplasty (RTSA) as an option for complex fractures in the elderly. The complexity of the technique in RTSA is increased because of the fracture. To find an advantage of locking stems in RTSA for the treatment of proximal humeral fractures, we designed a comparative study between fracture-dedicated locking stems vs. cemented stems.

MATERIALS AND METHODS

We retrospectively studied 58 patients treated with an RTSA after a fracture. We compared how the implant design and the tuberosity consolidation affects patient outcome through measuring range of motion and the Constant score.

RESULTS

The groups were similar in age, sex, time to surgery, and Constant score in the uninjured side. Patients treated with a dedicated locking noncemented stem performed better, with an increased Constant score (P > .05) and reached more mobility with no statistical significance. We found that 13 of the 24 fractures (54%) treated with a cemented stem consolidated, and 26 of 34 tuberosities (76%) healed in the noncemented locked stems. Patients with tuberosity consolidation acquired better range of motion and Constant scores (P < .05).

CONCLUSIONS

A dedicated stem improves tuberosity healing and increases outcomes seen in Constant scores. Tuberosity consolidation is a main goal when treating proximal humeral fractures with RTSA.

A New Stem Guide and a Tuberosity Anchoring "Lasso" System for Shoulder Hemiarthroplasty in the Treatment of Complex Proximal Humerus Fractures

Hemiarthroplasty implantation for proximal humerus fracture is challenging. In case of young demanding patients with functional rotator cuff, humeral head replacement is an option if open reduction internal fixation is not a viable solution. The criteria for success in terms of clinical outcomes and longevity are anatomic healing of the tuberosities and stem positioning (restoring correct height, version, and axis). The purpose of this article is to describe a technique including a new stem guide and a tuberosity anchor "lasso" system for the implantation of hemiarthroplasty in complex proximal humerus fractures. A standard delto-pectoral approach is performed. After humeral head removal and tuberosity mobilization and debridement, a stem-positioning system guarantees correct height and version of the humeral stem, established after anatomic reduction of the greater tuberosity. A centering device is added on the humeral stem to prevent any varus or valgus. Fixation of the tuberosities is achieved with 6 nonabsorbable sutures fixed on a polyester "lasso" anchoring system circling the humerus, respecting the direction of rotator cuff tendons and adding double circumferential tightening. After reduction of the implant, stability, and passive range of motion are assessed intraoperatively and fluoroscopic control of the prosthesis is performed. The patient is maintained in a sling in neutral rotation and passive motion is started after 4 weeks; active motion is allowed after 2 months. We believe this surgical technique could help limit complications and prevent revision of the humeral stem in case of further conversion to reverse shoulder arthroplasty.