Primary uncemented hemiarthroplasty for severe fractures of the proximal humerus

Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: a systematic review

OBJECTIVE

To report and compare the clinical and radiographic outcomes of patients treated with reverse shoulder arthroplasty (RSA) or hemiarthroplasty for acute complex proximal humeral fractures.

DATA SOURCES

A systematic review of PubMed, Cumulative Index to Nursing and Allied Health Literature, SportDiscus, and Cochrane Central Register of Controlled Trials was conducted. All published English language studies before January 2014 were reviewed for possible inclusion. Search terms included the following: proximal humerus, fracture, arthroplasty, hemiarthroplasty, RSA, and reverse total shoulder arthroplasty.

STUDY SELECTION

Studies reporting outcomes in human subjects after either RSA or hemiarthroplasty for acute proximal humeral fractures were assessed for inclusion. Additional inclusion criteria included a minimum clinical follow-up of 1 year. Level V evidence, basic science/cadaveric studies, and those studies reporting outcomes after revision arthroplasty were excluded.

DATA EXTRACTION

Patient demographics, clinical/radiographic outcomes, and complications were recorded. Posttreatment weighted means were calculated and reported. Homogenous outcome measures were analyzed, and a direct comparison of outcomes between treatment groups was performed.

CONCLUSIONS

Patients treated with RSA possess improved forward flexion (RSA: 118 degrees, Hemi: 108 degrees) but decreased external rotation (RSA: 20 degrees, Hemi: 30 degrees) compared with patients undergoing hemiarthroplasty after acute proximal humeral fracture. No significant clinical difference in either American Shoulder and Elbow Surgeons Shoulder Score (RSA: 64.7, Hemi: 63.0) or Constant score (RSA: 54.6, Hemi: 58.0) was identified. RSA was associated with an increased rate of clinical complications (9.6%) and a lower revision rate (0.93%) at short-term to midterm follow-up compared with hemiarthroplasty. RSA offers an acceptable surgical option for patients after complex acute proximal humeral fractures.

LEVEL OF EVIDENCE

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

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.

Proximal humeral fracture treatment in adults

Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.