Proximal Humerus 4

Proximal Humerus 4
movement from hemiarthroplasty in Nottingham appear poorer than results of conservative treatment in Sweden. Our results bring in to question the recommendations of Neer and Stableforth that comminuted fractures of the proximal humerus should be treated with prosthetic replacement. Further studies on the treatment of proximal humeral fractures are required.”

What can go wrong?

Þ Muldoon M.P., Cofield R.H., Complications of Humeral Head Replacement for Proximal Humeral Fractures, Instructional Course Lectures, Volume 46, 1997.

Complications
· reviewed complications in acutely treated proximal humerus fractures reported in 9 series.
· 203 shoulders, 71 complications (35%)
· wound problems 6, nerve injury 7 , instability 18, tuberosity nonunion or malunion 11, RSD 7, heterotopic bone 12, and glenoid arthritis 8.

Mayo Clinic Experience:
· 28 shoulders, treated within 2 months of injury, average follow-up 56 months
· 26 with no or mild shoulder pain
· Average active elevation 112o; better if done within 2 weeks.
· 13 complications – infection 3, instability 2, tuberosity nonunion 2, rotator cuff tear 2, RSD 1, glenoid arthritis 2, implant loosening 1.
So what are generally accepted indications for acute hemiarthroplasty?

Þ Zuckerman J.D., Cuomo F., Koval K., Proximal Humeral Replacement for Complex Fractures: Indications and Surgical Technique, Instructional Course Lectures, Volume 46, 1997.
· 4-part fractures
· 3-part fractures and fracture dislocations in osteopenic bone
· head-splitting fractures
· anatomic neck fractures in which internal fixation is not possible
· chronic dislocations with more than 40% of the articular surface involved

“In general, the reported results have been quite variable. Some series have reported more than 90% satisfactory results, while other series have reported less than 50%. The variability is difficult to explain, but is probably related to both patient selection and the outcome criteria used.”

If I put a hemiarthroplasty into a young patient, how long will it last?

Þ Sperling J.W., Cofield R.H., Rowland C.H., Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. Journal of Bone and Joint Surgery, 80A, 464-473, April 1998

· 78 hemiarthroplasties, 36 total shoulders between 1976-1985
· minimum 5 year follow-up (mean 12.3 years) on 74/78 hemiarthroplasties and 34/36 total shoulders
· all 114 shoulders used in survivorship.
· glenoid erosion in 46 (68%)
· 15 excellent, 24 satisfactory, 35 unsatisfactory or unsuccessful
· estimated survival: 92% at 5 years, 83% at 10 years, 73% at 15 years

* revision was higher for the thirty shoulders that had the hemiarthroplasty for the treatment of trauma than for the 28 that had it for RA.

“The data from our study indicate that shoulder arthroplasty provides marked long-term relief of pain and improvement of motion. However, when a rating system is applied, nearly half of all young patients who have a shoulder arthroplasty are found to have an unsatisfactory result. Care should be taken, and alternative methods of treatment should be actively considered, when either a hemiarthroplasty or a total shoulder arthroplasty is offered to patients who are fifty years old or less.”

If my internal fixation fails, what are the results of salvaging it with a hemiarthroplasty?

Þ Norris T.R., Green A., McGuigan F.X., Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. Journal of Shoulder and Elbow Surgery, 4(4): 271-280, Jul-Aug 1995

· 23 shoulders undergoing reconstruction following proximal humerus fracture
· 10 treated closed, 13 treated open. Malunions 17, nonunion 4, traumatic arthritis 14, AVN 9, deltoid paresis 4
· pain reduction in 95%, AFE 92, ER 27.
· only 53% able to do activities at or above shoulder level

“Late surgery for failed early treatment is technically difficult, and the results are inferior to those reported for acute humeral head replacement.