Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: A study of 46 patients followed up for an average of 4.4 years

doi:10.1016/j.jse.2007.03.017

Journal of Shoulder and Elbow Surgery

Volume 16, Issue 6, November–December 2007, Pages 766-773

https://doi.org/10.1016/j.jse.2007.03.017 Get rights and content

This study investigated 82 patients who underwent primary hemiarthroplasty for a severely displaced proximal humerus fracture at Danderyd Hospital between 1989 and 2002. According to the Neer classification system, fractures were 2-part in 2, 3-part in 20, and 4-part in 60. The prostheses used were 12 Neer-II, 39 Global, and 31 Bigliani-Flatow. Follow-up time averaged 4.4 years (range, 1-14 years). Twenty-two patients died, 9 were contacted by phone, and 5 were lost to follow-up. Forty-six patients underwent clinical examination, including the Constant score (CS) and radiographic examination. Mean CS for all patients was 42 of 100 points (range, 11-83 points). Radiologic evaluation revealed that 24 prostheses had migrated superiorly; this finding decreased the CS significantly. Ectopic bone developed in 25 patients, 16 had glenoid erosion, and 5 had displaced tuberosities; no correlation was found with the CS. Hemiarthroplasty usually prevented shoulder pain, but most patients had moderate function and poor strength. The reduced function appeared to be related to a lack of rotator cuff integrity.

Section snippets

Materials and methods

The study included 82 patients (65 women, 17 men) who underwent a primary hemiarthroplasty after a severely displaced 2-, 3-, or 4-part fracture of the proximal humerus between June 1989 and November 2002. Their mean age was 72 years (range, 42-91 years) at time of injury (Table I). Fractures were 2-part in 2 patients, 3-part in 20, and 4-part in 60 (Figure 1). The 2-part fractures were severely displaced fractures in 2 patients with osteoporotic bone, and the clinical judgement was that a

Results

Ten complications were recorded in 9 patients. One 90-year-old patient died 2 days postoperatively owing to cardiac insufficiency. An 86-year old patient sustained a cerebrovascular accident postoperatively and another 68-year-old patient had a transient ischemic attack. Only 1 patient contracted a superficial wound infection, which required débridement 45 days postoperatively. This patient, who was also diagnosed with severe alcoholism, sustained a pulmonary embolism postoperatively, although

Discussion

Neer²³ found that prosthetic replacement was the best treatment method for 4-part fractures and internal fixation for 3-part fractures. Later studies have shown that sex, age, mental status, fracture type, time between injury and hemiarthroplasty, rotator cuff status, length of the prosthesis, and duration of rehabilitation are factors that influence the final outcome.3, 4, 6 Neer reported excellent or satisfactory results after prosthetic replacement in 3- and 4-part fractures in 90% of the

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Cited by (87)

Does age affect patient outcomes after humeral head replacement in the treatment of acute proximal humeral fractures? A comparative cohort study with a minimum 10 years long-term follow-up
2024, Journal of Shoulder and Elbow Surgery
Humeral head replacement (HHR) is now rarely recommended for complex proximal humeral fractures (PHFs) in older patients. However, in relatively young and active patients with unreconstructable complex PHFs, controversy still exists regarding the treatment options of reverse shoulder arthroplasty and HHR. The goal of this study was to compare the survival, functional, and radiographic outcomes of HHR in patients aged <70 years and those aged ≥70 years after a minimum 10 years follow-up.
Eighty-seven out of 135 patients undergoing primary HHR were enrolled and then divided into 2 groups based on age: <70 years and ≥70 years. Clinical and radiographic evaluations were performed with a minimum follow-up of 10 years.
There were 64 patients (mean, 54.9 years) in the younger group and 23 patients (mean, 73.5 years) in the older group. The younger and older groups had comparable 10-year implant survivorship (98.4% vs. 91.3%). Patients aged ≥70 years had worse American Shoulder and Elbow Surgeons scores (74.2 vs. 81.0, P = .042) and lower satisfaction rates (12% vs. 64%, P < .001) than younger patients. At the final follow-up, older patients had worse forward flexion (117° vs. 129°, P = .047) and internal rotation (17 vs. 15, P = .036). More greater tuberosity complications (39% vs. 16%, P = .019), glenoid erosion (100% vs. 59%, P = .077), and humeral head superior migration (80% vs. 31%, P = .037) were also identified in patients aged ≥70 years.
Unlike the increased risk for revision and functional deterioration over time after reverse shoulder arthroplasty for PHFs in younger patients, a high implant survival rate with lasting pain relief and stable functional outcomes could be observed in younger patients after HHR during long-term follow-up. Patients aged ≥70 years had worse clinical outcomes, lower patient satisfaction, more greater tuberosity complications, and more glenoid erosion and humeral head superior migration than those aged <70 years. HHR should not be recommended for the treatment of unreconstructable complex acute PHFs in older patient populations.
Outcomes for a large metaphyseal volume hemiarthroplasty in complex fractures of the proximal humerus
2017, Journal of Shoulder and Elbow Surgery
A large metaphyseal volume shoulder hemiarthroplasty has been in use within our department since 2008; however, no clinical outcome data are available for this prosthesis apart from the designer surgeon series.
During a 5-year period, data were collected for 40 patients (30 women, 10 men) treated consecutively with the Zimmer Anatomical Shoulder Fracture hemiarthroplasty system (Zimmer, Warsaw, IN, USA).
The final analysis included 26 patients. The median age was 79 years (range, 58-91 years), and the median follow-up was 3.7 years (range, 2.0-5.8 years). The median Constant Score was 34 points (range, 16-70 points), and the median Oxford Shoulder Score was 27 points (range, 5-46 points). The greater tuberosity healed satisfactorily in 12 patients. Resorption of the greater tuberosity was seen radiologically in 18 patients. The presence of resorption had no significant effect on the Constant Score (P = .264) or the Oxford Shoulder Score (P = .469). Three patients (12%) required revision.
This is the first report from a nondesigner center for outcomes for this prosthesis to date. The results demonstrate reduced functional performance compared with the designer series.
Risk factors for glenoid erosion in patients with shoulder hemiarthroplasty: an analysis of 118 cases
2017, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
The clinical indications for revision surgery after hemiarthroplasty are usually a combination of pain and loss of function. On the humerus, these are most often associated either with degradation of the rotator cuff10,12 or, in fracture situations, with malposition of the tuberosities.6,9 On the glenoid side, however, glenoid erosion is 1 of the major causes for revision.5,10,14,18
Glenoid erosion is one of the main concerns in shoulder hemiarthroplasty. The goal of this study was to quantify glenoid erosion and to identify risk factors in patients with humeral hemiarthroplasty.
There were 118 shoulders in 113 patients available for a standardized retrospective review. Erosion was graded as follows: grade 1, none; grade 2, mild (erosion into subchondral bone); grade 3, moderate (medialization of subchondral bone with hemispheric deformation); or grade 4, severe. The findings were then analyzed for confounding factors using a multivariate analysis.
Mean follow-up was 31 months (range, 5-86 months). Negative predisposing factors for erosion were glenoid cysts (odds ratio, 5.4; P < .001, approximately 3 times more frequent in women), fatty infiltration of the rotator cuff musculature (R, 0.43; P < .001), and rheumatoid arthritis (odds ratio, 3.6; P = .049). A valgus position of the prosthetic head relative to the glenoid (angle >50°) appeared to lead to local destruction of the cartilage. The degree of erosion did not correlate with age and glenoid or humeral head size. Only 1 patient (of 30) with a fracture-type prosthesis developed progressive glenoid erosion.
In this series, favorable conditions for resistance to erosion after hemiarthroplasty were lack of glenoid cysts, intact glenoid cartilage, intact rotator cuff musculature, and a fracture situation. Age, the version of the glenoid, and the size of the prosthetic head showed no importance. The use of hemiarthroplasty seems to be associated with glenoid destruction in female patients with impending osteoarthritis, with rheumatoid arthritis, and if the head is implanted in a valgus position.
Does grafting of the tuberosities improve the functional outcomes of proximal humeral fractures treated with reverse shoulder arthroplasty?
2017, Journal of Shoulder and Elbow Surgery
Functional outcomes of reverse total shoulder arthroplasty (rTSA) can be improved by fixation of the tuberosities. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures treated with rTSA, with and without autologous grafting.
Thirty-three patients with proximal humeral fractures were treated with rTSA and tuberosity fixation. In 18 patients (group I; mean age, 75 years), tuberosity fixation was augmented with autografting; in 15 patients (group II; mean age, 71 years), graft augmentation was not used. The mean follow-up was 16.7 (range, 12-24) months in group I and 16.8 (range, 12-25) months in group II.
Radiologic tuberosity union was achieved in 14 of 18 (77.8%) patients who underwent autograft augmentation and in 6 of 15 (40.0%) patients treated without autografting. The mean American Shoulder and Elbow Surgeons (ASES) score was 69.6 ± 13.0 in group I and 51.0 ± 20.0 in group II. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 31.9 ± 24.0 in group I and 58.2 ± 24.6 in group II. A significant difference was detected between groups for ASES and DASH scores. Among shoulder range of motion measures, only forward flexion differed significantly between groups I and II (124° ± 23° vs. 98° ± 30°, respectively). External rotation muscle strength was significantly higher in group I (3.36 ± 1.46 kg) than in group II (2.39 ± 2.00 kg).
In the treatment of complex proximal humeral fractures in elderly patients by rTSA, cancellous block autograft augmentation can increase the rate of tuberosity union and improve functional outcomes.
Changing trends in the management of proximal humerus fractures in New York State
2020, Journal of Orthopaedics
Citation Excerpt :
HA has been considered the historical treatment of choice for arthroplasty in the elderly with poor bone quality and complex fracture patterns that are not suitable for internal fixation.7 Studies, however, have reported poor functional outcomes and no clear benefit towards quality of life with the use of HA compared to non-operative management.1,8–11 Recent literature has demonstrated an increased utilization of RSA and a decreased utilization of HA, particularly in the elderly population.4,5,12,13
Reverse shoulder arthroplasty (RSA) as an alternative to hemiarthroplasty (HA) as treatment for proximal humerus fractures has prompted a re-evaluation of utilization trends.
Operative treatment for proximal humeral fractures were analyzed using a New York State database.
After introduction as an ICD-9 code, RSA increased to 39.3% (m = +5.2%/year, r = 0.984). When stratifying by age ≥65, HA decreased to 7.7% (m = −2.8%/year, r = 0.962) while RSA increased to 50.6% (m = +6.4%/year, r = 0.985).
RSA overtook HA as the arthroplasty procedure of choice for proximal humerus fractures. In patients ≥65, RSA passed ORIF as the most prevalent procedure in 2017.
III, Descriptive Epidemiology Study, Large Database Analysis.
Anatomic Reduction of Greater Tuberosity Fragment for Shoulder Hemiarthroplasty: a Predictor of Good Clinical Outcome
2024, Archives of Bone and Joint Surgery

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Original articleMedium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: A study of 46 patients followed up for an average of 4.4 years

Section snippets

Materials and methods

Results

Discussion

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Fractures of the proximal humerus

Prosthetic replacement in acute fractures of the proximal humerus

Semin Arthroplasty

Indications and important features of primary prosthetic replacement in acute fracturesInstructional course 23, SECEC/ICSS Annual Meeting

Arthroplasty and acute shoulder traumaReasons for success and failure

Clin Orthop

A clinical method of functional assessment of the shoulder

Clin Orthop

Ectopic bone formation following low friction arthroplasty of the hip

Clin Orthop

Original article
Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: A study of 46 patients followed up for an average of 4.4 years