Operative treatment of malunion of a fracture of the proximal aspect of the humerus

[Fracture sequelae-when, how, what?]

The treatment of fracture sequelae following proximal humeral fractures presents a significant challenge, as they range from necrosis and pseudarthrosis to malunions. Classifications such as Boileau's facilitate diagnosis and treatment planning. Type 1 sequelae, characterized by necrosis, can be treated with either anatomical or reverse prostheses depending on the condition of the rotator cuff. Type 2 sequelae involve locked dislocations and may require bony reconstructions. Type 3 pseudarthrosis is managed either with joint-preserving techniques or prosthetic replacement, depending on the degree of degenerative changes. Type 4 malunions often benefit from corrective osteotomies and/or prosthesis implantation. Studies have demonstrated significant functional improvements following surgical intervention, with individual factors such as deformities or rotator cuff condition influencing treatment strategies.

Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review

While several proximal humerus fractures treated nonsurgically reach satisfactory outcomes, some become symptomatic malunions or nonunions with pain and dysfunction. When joint-preserving options such as malunion or nonunion repair are not optimal because of poor remaining bone stock or glenohumeral arthritis, shoulder arthroplasty is a good option. Because of the semiconstrained design of reverse shoulder arthroplasty, it is effective at improving function when there is notable bony deformity or a torn rotator cuff. Clinical studies have demonstrated reliable outcomes, and a classification system exists that is helpful for predicting prognosis and complications. By understanding the associated pearls and pitfalls and with careful management of the tuberosities, reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae.

Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae

Background

The aim of this study was to investigate the impact of computed tomography on the reliability of Boileau classification for proximal humerus fracture sequelae.

Methods

A prospective study was designed using STARD guidelines. We included all patients diagnosed with proximal humerus fracture sequelae who underwent surgery at our institution between 2017 and 2021. Preoperative radiographs and computed tomography scans were reviewed by three independent observers. Intra- and inter-observer reliability and the diagnostic accuracy of radiographs and computed tomography scans in detecting chronic dislocation, nonunion, and severe greater tuberosity dislocation were assessed.

Results

Fifty-two patients were included in the study. The overall interobserver agreement was low on both radiographs and computed tomography scans. On radiographic images, we found a sensitivity of 97%, 88.9%, and 84.1%, and a specificity of 58.3%, 40%, and 53.3% to detect chronic dislocation, nonunion, and greater tuberosity dislocation, respectively. On computed tomography scans we reported a sensitivity of 100%, 96.8%, and 93.7%, and a specificity of 91.7%, 86.7%, and 93.3% to detect chronic dislocation, nonunion, and greater tuberosity dislocation, respectively.

Discussion

Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. However, even using a three-dimensional evaluation of the deformity, the Boileau classification had a poor interobserver reliability.

Level of Evidence

I. Testing previously developed diagnostic criteria in a consecutive series of patients and a universally applied "gold standard."

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia

BACKGROUND

Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia.

METHODS

Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures.

RESULTS

Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management.

CONCLUSIONS

Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes

Background

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae.

Methods

Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk.

Results

The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P = .102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P = .004), lower rate of previous procedure (4.3% vs. 51.9%; P < .001), lower bone graft use (28.6% vs. 59.6%; P < .001), and a longer length of stay (5.9 vs. 3.0 days; P < .001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P = .523), forward elevation (98° vs. 93°; P = .627), external rotation (30° vs. 23°; P = .215), internal rotation score (4.0 vs. 4.5; P = .589), satisfaction (P = .592), ASES scores (64.4 vs. 57.1; P = .168), complications (27.1% vs. 28.8%; P = .836), or reoperations (11.4% vs. 19.2%; P = .229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P = .172), with 15-year reoperation rates of 13.7% and 24%, respectively (P = .098).

Conclusions

HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

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.

Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach

PURPOSE

Three part and four-part fractures of the proximal humerus offer challenges in reduction and plate fixation, with considerable debate about use of Deltoid splitting (DS) and Delto-pectoral (DP) approaches, especially when they involving the greater tuberosity. We prospectively compared the results using DS approach and DP approach in these cases, with special focus on functional outcomes, complications, and ease of tuberosity reduction.

MATERIALS AND METHODS

84 patients with three- and four-part proximal humerus fracture were alternately allocated the DP approach or DS approach for proximal humerus locking plate fixation. The outcome analysis was done by evaluating relative Constant score and ease of surgical reduction of greater tuberosity; radiological malunion was evaluated using Beredjiklian classification and complications were noted.

RESULTS

At mean follow-up of 23 months (19-48 months), the mean 'relative Constant score was 74.27 ± 8.19 in the DP group and 73.26 ± 8.02 in the DS group and the difference was statistically insignificant (p = 0.988). There was no significant difference with respect to shoulder ROM, abductor strength, radiological malunion or complications. However, the mean surgical time was significantly less (p value = 0.042) in DS group (65 ± 5 min) in comparison to DP group (92 ± 4.3 min); significantly less difficulties were documented by the surgeon in reducing the greater tuberosity in DS group(p value = 0.02).

CONCLUSION

Although surgical time was reduced and greater tuberosity reduction was easier in DS group, the other outcomes were similar; either surgical approach can be used based, and can be based on the experience and comfort level of the surgeon.

Rotator cuff to deltoid and pectoralis tendon to anatomic neck distances: methods for anatomic restoration of humeral height and tuberosity position in proximal humerus fractures for operative fixation and arthroplasty

Introduction

Proper anatomic tuberosity reduction and restoration of humeral height during surgical treatment of proximal humerus fractures leads to fewer complications and better outcomes. In the presence of significant displacement and comminution in proximal humerus fractures, the assessment of the correct tuberosity position and humeral height can be challenging. The goal of this cadaveric study was to provide new and useful measurements for intraoperative guidance of proper tuberosity position and humeral height when treating proximal humerus fractures with open reduction internal fixation, anatomic hemiarthroplasty, or reverse total shoulder arthroplasty.

Methods

A total of 28 cadaveric shoulders were dissected with a deltopectoral approach. The distance between the insertion of the supraspinatus tendon and the superior aspect of the deltoid tendon was measured (cuff to deltoid distance [CDD]). Secondly, the distance between the superior aspects of the pectoralis major tendon to the medial aspect of the anatomic neck (PND) was measured. Further, we sought to determine if these measurements would correlate to patient height and differ between gender.

Results

The average age of the donors was 65.3 years (64% male). The CDD and PND were 87.6 ± 10.6 and 16.6 ± 6.9 mm, respectively (mean ± standard deviation). There were no differences between females and males for the CDD (86.9 ± 9.4 vs. 87.2 ± 15.2 mm, P = .96) and PND (16.3 ± 9.1 vs. 17.1 ± 5.9 mm, P = .76). There was no correlation between the cadaver height and CDD (R2 = 0.1) and PND (R2 = 0.3).

Discussion

In this study, we describe 2 new measurement tools that can readily be applied intraoperatively during surgical treatment of proximal humerus fractures to aid in tuberosity reduction and humeral height assessment. These measurements were found to be independent of patient height and gender and can be used as a reference tool for most patients.

Acute surgical management of proximal humerus fractures: ORIF vs. hemiarthroplasty vs. reverse shoulder arthroplasty

BACKGROUND

Proximal humerus fracture treatment varies by surgeon preference and patient factors. This study compares patient and fracture characteristics, with outcomes between current surgical treatment options.

METHODS

Between 1999 and 2018, 425 proximal humerus fractures underwent acute surgical management: open reduction internal fixation (ORIF, n = 211), hemiarthroplasty (HA, n = 108), or reverse shoulder arthroplasty (RSA, n = 106). Patient and fracture characteristics included age, American Society of Anesthesiologists physical status classification (ASA), and fracture classification. Postoperative motion at 3, 6, and minimum 12 months (avg 20 ± 21 months), radiographic outcomes, and postoperative falls were analyzed.

RESULTS

Average age for treatment groups was 65 ± 13 years (range: 18-93 years). Fractures were classified as 2- (11%), 3- (41%), or 4-part (48%). Age, ASA, and fracture classification were associated with selected surgical management (P < .0001, =.001, <.0001, respectively). Outcomes showed a significant improvement in forward flexion from 3 months to 6 months in all groups (P < .0001). No difference in final motion was seen between groups. Radiographic union was higher in ORIF (89%), and similar between HA (79%) and RSA (77%, P = .005). Rate of reoperation was RSA 6.6%, ORIF 17.5%, and hemiarthroplasty 15.7% (P = .029). Postoperatively, 23% patients had at least 1 fall, of which 73% resulted in fractures.

CONCLUSION

Older patients with high ASA were treated with arthroplasty, and younger patients with lower ASA were treated with ORIF. All groups showed improvements in motion. At minimum 1 year of follow-up, there was no difference in motion between groups. ORIF and HA showed significantly more reoperations compared with RSA. Patients should be counseled about reoperation, fall risk, and prevention.

Does the etiology of a failed hemiarthroplasty affect outcomes when revised to a reverse shoulder arthroplasty?

BACKGROUND

The purposes of this study were to evaluate patient outcomes after revision of hemiarthroplasty to reverse shoulder arthroplasty (RSA) based on initial pathology, to determine the re-revision rate, and to identify characteristics that may predict subsequent re-revision.

METHODS

A total of 207 shoulder hemiarthroplasty, bipolar prosthesis, and humeral resurfacing cases revised to RSA between January 2004 and January 2017 were reviewed. Outcome measures included shoulder motion and American Shoulder and Elbow Surgeons and Simple Shoulder Test (SST) scores. Sixteen RSAs underwent re-revision. A case-control study with each revised RSA matched to 4 controls based on age, sex, and minimum 2-year follow-up was performed to evaluate for factors predicting re-revision.

RESULTS

The mean time from initial hemiarthroplasty to RSA was 3.6 years (range, 0.1-20 years). There were 114 patients with a minimum of 2 years' follow-up (mean, 57 months; range, 24-144 months). The most common initial diagnoses for hemiarthroplasty were fracture (n = 72), cuff tear arthropathy (CTA) (n = 22), and osteoarthritis (OA) (n = 20). Overall mean scores and range-of-motion values were as follows: American Shoulder and Elbow Surgeons score, 59 (95% confidence interval [CI], 54-64); SST score, 4 (95% CI, 4-5); forward flexion, 106° (95% CI, 96°-116°); and abduction, 95° (95% CI, 85°-105°). Compared with fracture cases, CTA cases had better forward flexion (P = .01) and abduction (P = .006) and OA cases had better SST scores (P = .02) and abduction (P = .04). The re-revision rate was 7.7% at a mean of 31 months (range, 0-116 months), with the most common diagnosis being fracture (10 of 16 cases). Humeral loosening (8 of 16 cases) was the most common failure mechanism, and larger glenosphere sizes were more likely to be revised.

CONCLUSION

Functional outcome scores of hemiarthroplasty cases revised to RSA were better for patients with OA than for patients with CTA or fracture. Cases of hemiarthroplasty for fracture had decreased motion after revision to RSA compared with CTA and OA. Humeral loosening was the most common failure mechanism.

Early displacement of two part proximal humerus fractures treated with intramedullary proximal humeral nail

Introduction

Proximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement.

Methods

A retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014-2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement.

Results

Mean age was 66.6 (range 17-93), and mean follow up was 20 months (range 6-40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (-0.41, p = 0.04).

Conclusions

PHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Can objective criteria for poor tolerance of proximal humerus malunion be identified?

BACKGROUND

Malunion of the proximal humerus is common and variably tolerated. Classifications developed for proximal humerus malunion (PHM) rely on standard radiographs, which underestimate bone fragment displacement and lack accuracy. The clinical tolerance of PHM is subjective, and revision surgery is not always necessary. The primary objective of this study was to assess the reproducibility and relevance of four CT angle measurements for objectively quantifying the morphological disharmony caused by PHM in a control population then in a population with PHM. The secondary objectives were to identify angle cut-offs and to assess the correlations between angle values and the clinical tolerance of PHM.

HYPOTHESIS

Objective criteria for assessing proximal humerus malunion can be identified using CT scans.

MATERIALS AND METHODS

Four angles were chosen to quantify proximal humerus disharmony: the angles between the humeral head and the glenoid in the coronal plane (HGCo) and axial plane (HGAx), the angle of tuberosity divergence in the axial plane (TDAx), and the centrum collum diaphyseal angle (CCD). The reproducibility of measurements of the four angles on computed tomography (CT) views was evaluated in a control population and in 46 patients with PHM. To this end, the reproducibility of reference slice selection was determined and intra- and interobserver reproducibility of the angle measurements was then assessed. Patients with PHM were divided into two groups based on clinical tolerance to allow testing for disharmony parameters associated with poor clinical tolerance, which was defined as functional impairment and surgical revision.

RESULTS

Slice selection was found to be reproducible. The Bland-Altman plot indicated that the angle measurements in both the controls and the patients were reproducible within ±2 SDs. Intraclass correlation coefficient values ranged from fair to excellent for all angles in both the controls and the patients. The mean TDAx was higher in the patients than in the controls (72.0° vs. 56.1°, P<0.05) and, within the PHM group, was higher in the subgroup with good vs. poor clinical tolerance (75.8° vs. 69.5°, P<0.05). The CCD angle was greater in the controls than in the patients (129.8° [range, 128.3°-131.3°] vs. 125.9° [range, 122.9°-128.9], respectively) and was significantly greater in the PHM subgroup with good vs poor clinical tolerance (131.4° vs. 122.3°, respectively; P=0.007). The HGCo and HGAx angles were significantly greater in the patients than in the controls (HGCo: 66.6° vs. 52.2°, respectively; HGAx: 17.5° vs. 13.3°, respectively, P=0.55).

DISCUSSION

The measurement method described here provides a quantitative assessment of postfracture disharmony based on four angles, the HGCo, HGAx, and TDAx. Measurement of these four angles on CT images was found to have good intra- and interobserver reproducibility. The angle values were significantly greater in the patients with PHM than in the controls. Within the patient group, the subgroup with poor clinical tolerance had smaller values of the TDAx, CCD, and HGAx angles and a greater value of the HGCo angle.

LEVEL OF EVIDENCE

IV, retrospective observational study.

"90/90" Plating of proximal humerus fracture-a technical note

INTRODUCTION

While locking plates have markedly improved fixation of proximal humerus fractures, a cohort of fractures remains difficult to treat. This cohort has been identified as fractures with marked medial comminution and varus deformity. Loss of reduction and fixation failure are the most frequently reported complications for this cohort. We report the use of an orthogonal 1/3 tubular plate to augment the proximal humerus locking plate.

METHODS

The subject underwent osteosynthesis for a four-part proximal humerus fracture with medial comminution. Fixation was performed within 24 h of injury. Standard deltopectoral approach exposed the fracture. Sutures were sited to control the tuberosities and cuff. Initial reduction was held with a K-wire and augmented with a three-hole 1/3 tubular plate. Proximal humerus locking plate was sited in standard fashion including locked medial support screws. Reduction was confirmed both clinically and with intra-operative radiography.

RESULTS

The technique provided satisfactory results. At 6 months, the fracture had fully united with no loss of reduction. At 1 year, the patient had excellent range of motion.

CONCLUSION

The use of a 1/3 tubular plate to augment fixation of proximal humerus fractures with medial comminution may provide a simple, reproducible, and cost-effective method to decrease loss of reduction and subsequent malunion.

Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised?

BACKGROUND

Primary shoulder hemiarthroplasty is used to address a range of glenohumeral disorders, including fracture, arthritis, avascular necrosis, and capsulorrhaphy arthropathy; some patients with hemiarthroplasties undergo revision surgery for persistent pain or residual shoulder dysfunction. The literature does not clarify the features of the hemiarthroplasties having repeat surgery in a way that can guide surgeons' efforts to minimize the need for revision. To help address this gap, we analyzed the characteristics of patients from our region for whom we performed surgical revision of a prior humeral hemiarthroplasty QUESTIONS/PURPOSES: (1) What are the common characteristics of shoulder hemiarthroplasties having a revision? (2) What are the common characteristics of the subset of revised shoulder hemiarthroplasties that were performed for fracture? (3) What are characteristics of the subset of all revised hemiarthroplasties that were associated with glenoid bone erosion?

METHODS

Data for 983 patients for whom we performed a surgical revision of any type of shoulder arthroplasty between January 1991 and January 2017 were identified in our longitudinally maintained institutional arthroplasty revision database. In each case, revision had been elected by shared patient and surgeon decision-making after consideration of the disorder, degree of compromised comfort and function, treatment alternatives, and the risks of surgery. Of these 983 patients, 359 (37%) had a revision of a prior primary hemiarthroplasty; these patients were the subjects of this investigation. In this group of patients, we investigated the patient demographics, shoulder characteristics, prerevision radiographic findings, and findings at revision surgery. No patients were excluded. The patients having revision of primary hemiarthroplasties had severe loss of self-assessed shoulder comfort and function, with Simple Shoulder Test (SST) scores averaging 2.2 ± 2.2 of the maximum score of 12. The majority of these patients (81%) were women. The medical records of these 359 patients were abstracted to determine the diagnosis for the index primary hemiarthroplasty, clinical characteristics before surgery, and findings at surgical revision. One hundred twelve of the arthroplasties had been performed for fracture-related diagnoses; a subgroup analysis was performed on these patients. Two hundred seventy-three of the 359 patients (76%) had plain radiographs performed within 3 months before revision surgery that were adequate for assessing the radiographic characteristics of the glenoid, humerus, humeral component, and glenohumeral relationships; a subgroup analysis was performed on these patients. The degree of glenoid erosion was measured by a single observer in accordance with established criteria: Grade 1 is no erosion, Grade 2 is erosion limited to subchondral bone, Grade 3 is moderate erosion with medialization, and Grade 4 is medialization beyond the coracoid base. Some patients were included in both of these subgroups.

RESULTS

Common characteristics of the revised hemiarthroplasties included female sex (81%), rotator cuff (89 of 359; 25%) or subscapularis (81 of 359; 23%) failure, problems related to prior fracture (154 of 359; 43%), glenoid erosion 125 of 359; 35%), and component malposition (89 of 359; 25%). Hemiarthroplasties performed for fracture-related problems often were associated with tuberosity malunion or nonunion (58 of 79; 73%) and decentering of the humeral component on the glenoid surface (45 of 71; 63%). Major erosion of the bony glenoid (Grade 3 or 4) was more common in decentered hemiarthroplasties (42 of 102; 41%) than for centered hemiarthroplasties (36 of 146; 25%) (Fisher's exact p = 0.008) and more common for hemiarthroplasties positioned in valgus (28 of 50; 56%) than for those positioned in neutral or varus (40 of 188; 21%) (Fishers' exact p < 0.0001).

CONCLUSIONS

These findings suggest that some revisions of primary hemiarthroplasties may be avoided by surgical techniques directed at centering the prosthetic humeral articular surface on the glenoid concavity using proper humeral component positioning and soft tissue balance, by avoiding valgus positioning of the humeral component, and by managing glenoid disorders with a primary glenohumeral arthroplasty rather than a hemiarthroplasty alone. When durable security of the subscapularis, rotator cuff, and tuberosities is in question, the surgeon may consider a reverse total shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Reverse total shoulder arthroplasty

Since the introduction of reverse total shoulder arthroplasty (RTSA) in 1987 (in Europe) and 2004 (in the United States), the number of RTSAs performed annually has increased.

Although the main indication for RTSA has been rotator cuff tears, indications have expanded to include several shoulder conditions, many of which involve dysfunction of the rotator cuff.

RTSA complications have been reported to affect 19% to 68% of patients and include acromial fracture, haematoma, infection, instability, mechanical baseplate failure, neurological injury, periprosthetic fracture and scapular notching.

Current controversies in RTSA include optimal baseplate positioning, humeral neck-shaft angle (135° versus 155°), glenosphere placement (medial, lateral or bony increased offset RTSA) and subscapularis repair.

Improvements in prosthesis design, surgeon experience and clinical results will need to occur to optimize this treatment for many shoulder conditions.

Cite this article: EFORT Open Rev 2018;3:58–69 DOI: 10.1302/2058-5241.3.170044

The Role of Reverse Shoulder Arthroplasty in Management of Proximal Humerus Fractures with Fracture Sequelae: A Systematic Review of the Literature

Fracture sequelae of the proximal humerus poses a complex management decision due to the frequent deformity and its consequences on the peri-articular soft tissues. These patients are frequently elderly with significant medical comorbidities. Due to the age of the patient there is frequently rotator cuff deficiency and therefore the reverse shoulder arthroplasty (RSA) becomes the arthroplasty of choice. We have performed a systematic review of the literature and report nine studies presenting RSA for the treatment of fracture sequelae of the proximal humerus. It is clear that RSA can improve the range of movement and function following proximal humerus fracture sequelae. However, there is a risk of significant complications including dislocation (16.7%), infection (6.7%), intra-operative fracture (3%) and neurological injury (2.6%). There is a need to invest in future prospective comparative studies and randomised trials to further test RSA in fracture sequelae patients. This will provide us with information regarding the longevity of different prosthesis, outcomes and cost-effectiveness of treatment.

Three-dimensional corrective osteotomies of complex malunited humeral fractures using patient-specific guides

BACKGROUND

Corrective osteotomies of malunited fractures of the proximal and distal humerus are among the most demanding orthopedic procedures. Whereas the restoration of the normal humeral anatomy is the ultimate goal, the quantification of the deformity as well as the transfer of the preoperative plan is challenging. The purpose of this study was to provide a guideline for 3-dimensional (3D) corrective osteotomies of malunited intra-articular fractures of the humerus and a detailed overview of existing and novel instruments to enlarge the toolkit for 3D preoperative planning and intraoperative realization using patient-specific guides.

METHODS

We describe the preoperative 3D deformity analysis, relevant considerations for the preoperative plan, design of the patient-specific guides, and surgical technique of corrective osteotomies of the humerus.

RESULTS

The presented technique demonstrates the benefit of computer-assisted surgery for complex osteotomies of the humerus from a preoperative deformity analysis to the creation of feasible surgical procedures and the generation of patient-specific guides.

CONCLUSIONS

A 3D analysis of a post-traumatic deformity of the humerus, 3D preoperative planning, and use of patient-specific guides facilitate corrective osteotomies of complex malunited humeral fractures.

[Posttraumatic arthrosis of the glenohumeral joint. From partial resurfacing to reverse shoulder arthroplasty]

BACKGROUND

Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.

OBJECTIVE

Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.

METHODS

Selective literature review and description of personal experience.

RESULTS

The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.

CONCLUSION

Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

[Corrective osteosynthesis of proximal humeral fractures. Technique and prospective results]

BACKGROUND

Fracture sequelae of proximal humeral fractures arise following nonoperative and operative forms of treatment. Due to a painful restricted range of motion, in most cases shoulder prostheses are implanted. There is a need for joint-preserving alternatives especially for younger patients.

OBJECTIVES

The aim of this study was to evaluate the surgical techniques and prospective results of fracture sequelae of proximal humeral fractures following corrective osteosynthesis.

MATERIAL AND METHODS

A total of 11 patients (4 female) with an average age of 53 years (range 29-71 years) and a mean follow-up of 19.5 months were included prospectively. The preoperative and postoperative ranges of motion of the affected shoulder were compared by statistical means. At the time of follow-up the constant score (CS), the simple shoulder test (SST) and the simple shoulder value (SSV) were assessed.

RESULTS

Fracture sequelae were classified as type II in four patients, as type III in two and as type IV in five patients using the Boileau classification. Shoulder flexion (p = 0.006), abduction (p = 0.003) and external rotation (p = 0.02) improved significantly in the postoperative course. The mean age and gender-adapted CS was 74.8 ± 19.9 % at the time of follow-up, 10.1 out of 12 points were reached in the SST and the mean SSV was 77 %.

CONCLUSION

Corrective osteosynthesis of fracture sequelae (Boileau types II-IV) of proximal humeral fractures appears to be a good alternative to implantation of shoulder prostheses, especially in younger patients (< 60 years of age).

Modified osteotomy for symptomatic malunion of the humeral greater tuberosity

Here, we describe a modified osteotomy for malunion of the greater tuberosity that facilitates bone union and prevents symptom recurrence. The 3 most important features of this technique are: (1) osteotomizing the displaced fragment that includes the bed of the fracture, (2) placing figure-of-eight sutures by passing suture threads from inside the medullary cavity through osseous holes made in the metaphysis, and (3) pushing the distal end of the osteotomized fragment into the medullary cavity and fixing it in place. This procedure was performed on 10 patients who complained of clinical symptoms derived primarily from greater tuberosity malunion after fractures of various morphologies. Eight of these patients were available for follow-up examinations over 2 postoperative years. Constant score ratios comparing the repaired side to the uninjured side ranged from 82% to 100%. These results support the use of this modified osteotomy in achieving favorable bone union and in creating sufficient subacromial space to resolve most symptoms caused by these malunited proximal humeral fractures.

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.

Arthroscopic management of occult greater tuberosity fracture of the shoulder

PURPOSE

The purpose of this retrospective study was to evaluate the early results of arthroscopic treatment in patients with missed occult greater tuberosity (GT) fracture of the humerus using the arthroscopic suture-bridge fixation technique.

METHODS

Between January 2007 and August 2010, we used arthroscopic suture-bridge fixation in 15 cases of missed occult GT fractures, which were referred to our department with persistent symptoms following trauma, despite physical therapy. Occult GT fracture was diagnosed with bone marrow edema seen on magnetic resonance imaging in all patients. There were 13 male and 2 female patients with a mean age of 45 years (range 31-67 years). Mean time period until the surgery following the initial trauma was 4 months (1.5-12 months). For the measurement of clinical outcomes, we assessed the range of motion and evaluated the University of California, Los Angeles (UCLA) American Shoulder and Elbow Surgeons (ASES) scores and simple shoulder test (SST).

RESULTS

The early clinical results were evaluated in these patients at a mean of 24 months (range 14-36 months) after surgery. All the patients were satisfied with the surgery. The mean UCLA, ASES, and SST scores improved from preoperative 15, 39, and 2 to postoperative 33, 91, and 11, respectively (P < .05). Mean forward flexion, abduction, external rotation at the neutral position, and internal rotation were improved to 159°, 155°, 24°, and L1, respectively, at the final follow-up.

CONCLUSION

In the occult GT fracture with persistent shoulder symptoms, arthroscopic suture-bridge fixation and early rehabilitation showed excellent clinical outcomes on a short-term follow-up study.

LEVEL OF EVIDENCE

Retrospective review, Level IV.

Malunion of the proximal humerus

Malunion of a proximal humerus fracture is difficult to manage once bone union has been achieved in a wrong position. Malunion may be encountered after conservative treatment or internal fixation of fractures, and also around a joint prosthesis. The malunion can involve the greater and lesser tuberosities, humeral head, bicipital groove, or the entire epiphysis. The nature of the malunion must be precisely characterized. Malunion can affect bone structures and the articular surface; any resulting displacements must be carefully measured. Clinical assessments will help to evaluate the functional repercussions and determine the need for correction. Radiographic imaging and CT scan guide the treatment plan. Arthroscopic surgery (acromioplasty or tuberoplasty) can be used to treat biceps tenosynovitis or impingement syndrome in cases where full correction of the malunion is not required. Corrective surgery of a metaphyseal malunion is used to realign the proximal humeral into the proper position. Tuberosity osteotomy is the main predictor for a poor outcome following secondary arthroplasty.

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.

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.

Proximal humeral malunion treated with reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the outcomes of patients with proximal humeral malunions treated with reverse shoulder arthroplasty (RSA).

MATERIALS AND METHODS

Sixteen patients were treated with RSA for sequelae of a proximal humeral fracture with a malunion. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test, visual analog scale [VAS] score for pain and function, range of motion, and patient satisfaction) and radiographs were evaluated at a minimum follow-up of 2 years. Wilcoxon signed-rank tests were used to analyze preoperative and postoperative data.

RESULTS

All patients required alteration of humeral preparation with increased retroversion of greater than 30°. The total ASES score improved from 28 to 63 (P = .001), ASES pain score from 15 to 35 (P = .003), ASES functional score from 15 to 27 (P = .015), VAS pain score from 7 to 3 (P = .003), VAS function score from 0 to 5 (P = .001), and Simple Shoulder Test score from 1 to 4 (P = .0015). Forward flexion improved from 53° to 105° (P = .002), abduction from 48° to 105° (P = .002), external rotation from 5° to 30° (P = .015), and internal rotation from S1 to L3 (P = .005). There were no major complications reported. Postoperative radiographic evaluation showed 2 patients with evidence of notching and 1 patient with proximal humeral bone resorption.

CONCLUSION

RSA is indicated for treating the most severe types of proximal humeral fracture sequelae. The results of RSA for proximal humeral malunions with altered surgical technique yield satisfactory outcomes in this difficult patient population.

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.

Use of a partial humeral head resurfacing system for management of an osseous mechanical block to glenohumeral joint range of movement secondary to proximal humeral fracture malunion

Malunion of proximal humeral fractures can lead to a severely impaired shoulder function. Loss of motion is often the main issue in patients and can be secondary to osseous, soft-tissue as well as neurological damage to the shoulder. Malunion of the articular surface of the humeral head can lead to pain, chronic degenerative changes secondary to joint incongruity and mechanical block to the range of movement. A 46-year-old otherwise healthy male chef presented with malunion and collapse of his previous plate fixation for a four-part proximal humerus fracture. We describe the first documented case of the use of a focal resurfacing system for dealing with such an osseous mechanical block in the presence of an otherwise preserved articular surface in a high-demand patient. HemiCAP can be successfully used in proximal humeral fracture malunion where there is a localized cartilage defect, allowing restoration of joint congruity while preserving the bone stock.

How does a varus deformity of the humeral head affect elevation forces and shoulder function? A biomechanical study with human shoulder specimens

OBJECTIVES

A biomechanical study was performed to test the hypothesis that a varus deformity of the humeral head decreases supraspinatus (SSP) efficiency and increases deltoid elevation forces in human specimens.

METHODS

Twenty-four fresh-frozen human shoulder specimens were prepared by preserving the rotator cuff and deltoid. A defined, medial closed-wedge osteotomy was performed and lateral locked plate applied to simulate a varus deformity of 45° in Group I (n = 8) and 20° in Group II (n = 8). The control group (n = 8) was not osteotomized. The effect of the deformities on arm elevation forces was measured in a robot-assisted shoulder simulator under a physiologically loaded rotator cuff during three elevation phases. Phase 1 encompassed 0° to 30°, Phase 2 was from 30° to 60°, and Phase 3 included 60° to 90° of shoulder elevation.

RESULTS

SSP efficiency, defined as the degree of elevation attained per unit muscle force, was significantly less in Group I compared with Group II (P = 0.036) and the control group (P = 0.039) (Group I = 0.12 ± 0.03°/N, Group II 0.18 ± 0.05°/N, and control group 0.24 ± 0.10°/N). Under physiological loading of the rotator cuff, the deltoid (DELT) elevation forces were significantly greater in Group I (Pphase 1 = 0.015, Pphase 3 = 0.001) and Group II (Pphase 1 = 0.015, Pphase 3 = 0.006) compared with the control group in elevation Phase 1 (Group I: 3.20 ± 1.04 N/°, Group II: 3.03 ± 0.96 N/°, control group: 2.01 ± 0.53 N/°) and Phase 3 (Group I: 2.50 ± 0.85 N/°, Group II: 1.55 ± 0.28 N/°, control group: 1.21 ± 0.18 N/°). When the SSP was unloaded, the DELT elevation forces were significantly greater in Group l than in Group II (P = 0.040) and the control group (P = 0.004) during elevation Phase 3 (Group I: 2.12 ± 0.60 N/°, Group II: 1.47 ± 0.34 N/°, control group: 1.24 ± 0.32 N/°).

CONCLUSIONS

A varus deformity of the humeral head changes the pretension of the rotator cuff and results in a significantly decreased SSP efficiency (45° varus) and significantly higher arm elevation forces (20° varus). Clinically, the study's findings are relevant because they indicate that varus deformities of more than 20° should not be accepted intraoperatively and might indicate the need for surgical correction in case of subsequent symptoms.

Recession wedge osteotomy of the greater tuberosity for proximal humeral varus

Proximal humeral varus has multiple etiologies and may lead to impingement and reduced shoulder range of motion, particularly abduction and forward elevation. Valgus osteotomies have been described at the level of the surgical neck yielding acceptable results. This article describes a case of a male electrician who was treated for symptoms associated with proximal humeral varus of the right shoulder. He underwent an osteotomy of the greater tuberosity designed to reduce impingement and improve range of motion. The patient had previously undergone two separate surgical procedures for a simple bone cyst, but continued to have reduced shoulder function secondary to a prominent greater tuberosity. Preoperative and follow-up radiographs, physical examinations, and shoulder function were retrospectively reviewed for 32 months. Following treatment, active forward elevation improved from 130° preoperatively to 170°, abduction from 90° to 170°, external rotation from 45° to 70°, and internal rotation from T10 to T7. The patient reported relief of pain, impingement-free range of motion, and full symmetric function equal to that of his contralateral shoulder. Radiographs demonstrated osteotomy union, improved greater tuberosity/acromial clearance, and no impingement with abduction. Postoperative stiffness was the only complication noted for which a shoulder manipulation was performed under anesthesia. Thus, recession wedge osteotomy of the prominent greater tuberosity may serve as a viable surgical approach to reducing impingement and improving clinical function in proximal humeral varus.

Arthroscopic tuberoplasty for subacromial impingement secondary to proximal humeral malunion

Subacromial impingement secondary to malunion of proximally displaced greater tuberosity fractures may be treated with arthroscopic acromioplasty in patients with slight displacements, but open anatomical repositioning of the malunited fragment is recommended when more severe deformities exist. This deformity may also be addressed by abrading the protruding proximal portion of the greater tuberosity (tuberoplasty). However, this procedure would require full elevation of the rotator cuff insertion if performed with open surgery. This article reports a technique of arthroscopic tuberoplasty based on combined intra- and extra-articular transtendinous abrasion of the proximal end of the greater tuberosity for malunions with severe upward displacement of the greater tuberosity. This procedure allows for major preservation of the rotator cuff insertion.

Arthroscopic fixation for a malunited greater tuberosity fracture using the suture-bridge technique: technical report and literature review

Greater tuberosity of the humerus malunion is relatively uncommon, and open techniques are the treatment of choice in most cases. Recent advances in arthroscopic techniques for treatment of greater tuberosity fractures have produced promising results. The use of arthroscopic techniques for the treatment of proximal humerus malunion, however, has been reported only rarely in the literature. This case report describes the malunited greater tuberosity fracture treated arthroscopically using the suture-bridge technique.

Arthroscopic treatment for malunions of the proximal humeral greater tuberosity

The purpose of this article was to report an arthroscopic treatment method for greater tuberosity malunion. Eight patients with malunion of the greater tuberosity were treated by arthroscopic acromioplasty, detachment of rotator cuff, tuberoplasty of the greater tuberosity and repair of the rotator cuff. On the basis of the UCLA rating scale, the overall score increased from 11.1 (range 9-14) to 30.2 (range 25-35) postoperatively, with one excellent result, six good results, and one poor result. All patients had less pain than preoperatively. Full activity level was achieved in two patients, five patients had only slight functional restriction, and one patient had mild limitation in activities of daily living. Seven patients returned to their previous occupations without restrictions. One patient did not return to work because of residual upper extremity weakness. We conclude that arthroscopic tuberoplasty is a good method for the treatment of greater tuberosity malunion.

Shoulder arthroplasty: prosthetic options and indications

Glenohumeral arthropathy and failed shoulder arthroplasty can lead to debilitating pain, reduced motion and strength, and limited function. Primary osteoarthritis, posttraumatic osteoarthritis, rheumatoid arthritis, cuff tear arthropathy, and osteonecrosis are common in this patient population. Shoulder arthroplasty may fail because of problems with the prosthesis, such as wear, loosening, and dislocation of the components, or because of bone and soft-tissue problems, such as glenoid arthrosis and rotator cuff tear. The disparate pathogenesis of these processes presents unique challenges to the treating surgeon and requires diagnosis-specific treatment options, whether involving hemiarthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty. Until recently, prosthesis options were limited to a stemmed humeral component with or without a polyethylene glenoid component. The array of prosthetic options currently available allows individualized treatment.

Management of proximal humeral nonunions and malunions

Surgical treatment of proximal humeral nonunions and malunions are technically challenging. Osteosynthesis with bone grafting for the treatment of nonunions is indicated in young, active patients with adequate bone stock in the proximal fragment and preservation of the glenohumeral articular surfaces. Corrective osteotomy may be a reasonable option for proximal humeral malunions in young patients without evidence of degenerative joint disease. Arthroplasty for proximal humerus nonunions and malunions has a guarded outcome because of limitations in shoulder motion, but pain relief is more consistently improved upon.

Isolated tuberosity fractures of the proximal humeral: current concepts

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.