Perioperative fracture-dislocation of the humeral head during a resurfacing hemiarthroplasty

We report a case of perioperative fracture-dislocation of the humeral head produced during the reaming for a resurfacing replacement hemiarthroplasty (RRH) in a 79-year old woman. This is a surgical complication not previously described in the literature for this type of prosthesis design. Resurfacing humeral head implant has been noted as a useful treatment for glenohumeral arthropathies, also in elderly people, with a very low incidence of complications. However, as we report, they are possible.It is advisable that conventional stemmed implants could be available when RRH is performed.     

Current concepts in distal humeral hemiarthroplasty

Multi-fragmentary intra-articular fractures of the distal humerus remain a challenge for both patients and surgeons. Open Reduction internal fixation remains the gold standard, however in older patients with comminuted fractures this might not be feasible. There is a growing interest in hemi-arthroplasty as a solution for these cases. However the current experience and follow-up in limited. This review article intends to describe the current concepts in elbow hemiarthroplasty in dept. we will discuss the historical use of these implants, as well as the intricacies of more modern devices. Next we will elaborate an surgical planning, approach, and technical pearls. We will lay out a rehab protocol used by the senior author, and with some considerations for the future.     

Healing of reamed glenoid bone articulating with a metal humeral hemiarthroplasty: a canine model.

This study characterizes the healing response of the glenoid after spherical reaming and prosthetic humeral head replacement in a canine model of glenohumeral hemiarthroplasty. The right glenoid of twelve skeletally mature female dogs was reamed to a uniform radius of curvature, removing all cartilage down to bleeding subchondral bone. The glenoid was not resurfaced. The humeral head was replaced with a stemmed metal prosthesis. Post-surgery, the operated limbs were immobilized for seven days, with motion allowed ad libitum thereafter. Fluorescent bone labels were administered to identify bone formation. These procedures were not complicated by instability, infection or death. Six animals were euthanized at 10 week and six more at 24 week. The intact glenohumeral joints were evaluated by gross examination, assessment of glenoid concavity, and light microscopy of methylmethacrylate sections. At 10 week, vascular fibrous tissue partially covered the glenoid, maintaining a concave surface congruent with the prosthetic humeral head. New bone formed at the margin of the glenoid, and the density of the periarticular trabecular bone increased. At 24 week, the healing was more advanced; thick fibrocartilaginous tissue covered the entire glenoid surface. These results demonstrate that spherical glenoid reaming produced a consistent healing response characterized by remodelling of the reamed bony concavity to a congruent, living, smooth, securely attached interface articulating with the humeral prosthesis.     

Revision of failed humeral head resurfacing arthroplasty

Purpose:The purpose of this study is to assess the outcomes of a consecutive series of patients who underwent revision surgery after humeral head resurfacing (HHR). Our joint registry was queried for all patients who underwent revision arthroplasty for failed HHR at our institution from 2005 to 2010. Eleven consecutive patients (average age 54 years; range 38-69 years) that underwent revision of 11 resurfacing arthroplasties were identified. The primary indication for resurfacing had been osteoarthritis in six, glenoid dysplasia in two, a chondral lesion in two, and postinstability arthropathy in one patient. The indication for revision was pain in 10 and infection in one patient. Seven patients had undergone an average of 1.9 surgeries prior to resurfacing (range 1-3).Results:At a mean follow-up of 3.5 years (range 1.6-6.9 years), modified Neer score was rated as satisfactory in five patients and unsatisfactory in six. Abduction and external rotation improved from 73° to 88° (P = 0.32) and from 23° to 32° (P = 0.28) respectively. Reoperation was required in two patients, including one hematoma and one revision for instability.Conclusion:Outcomes of revision of HHR arthroplasty in this cohort did not improve upon those reported for revision of stemmed humeral implants. A comparative study would be required to allow for definitive conclusions to be made.     

肱骨近端骨折反置式人工全肩关节置换术与人工肱骨头置换术的比较

SummaryEarly evidence from two small retrospective cohort studies suggests that reverse shoulder arthroplasty appears similar to hemiarthroplasty for the treatment of proximal humeral fractures in an elderly population.One study found no significant differences for either functional outcomes or range of motion at follow-up.The other study found that Constant scores and range of motion may be better for reverse shoulder arthroplasty.However,only retrospective cohort studies were available,so no definitive conclusions can be drawn from these two small 2项小样本回顾性队列研究的结论认为,反置式人工全肩关节置换术(RSA)与人工肱骨头置换术(HA)在治疗老年性肱骨近端骨折方面疗效相当.其中1项研究发现,随访期间两种方法在功能恢复和活动范围改善方面无明显统计学差异.另1项研究则认为经过RSA治疗的患者,Constant肩部评分结果和肩部活动范围的改善要更好.但是,目前的研究结果来自于回顾性队列研究,因此并不能从中得出比较确切的结论.     

Axillary artery thrombosis after humeral resurfacing arthroplasty

Shoulder arthroplasty is a very successful procedure that places significant technical demands on the surgeon. Complications, such as neural injury and postoperative fracture, have been reported in the literature. In this article, I describe 2 cases of axillary artery thrombosis that occurred after humeral resurfacing arthroplasty. Case 1 involved a 59-year-old woman who underwent humeral resurfacing arthroplasty. In the immediate postoperative period, a vascular insult was diagnosed by decreased radial pulse and perfusion. Immediate retrograde angiography revealed occlusion of the axillary artery near the level of the prosthesis. Retrograde balloon thrombectomy removed an arterial thrombus and circulation was restored. Case 2 involved a 64-year-old woman with a latent decrease in radial pulse amplitude after humeral resurfacing. Unsuccessful balloon thrombectomy necessitated a reverse saphenous vein bypass graft. Axillary artery injury that occurs after anterior shoulder dislocation is well documented. Shoulder position during humeral resurfacing reproduces anterior glenohumeral dislocation and may tense the axillary artery against the edge of the pectoralis minor. Elderly patients are predisposed to vascular injury because of loss of arterial elasticity. Meticulous neurovascular examination is crucial throughout the postoperative period, as collateral circulation may conceal perfusion deficits. Prompt recognition of vascular injury may prevent circulatory compromise.     

Stability of tuberosity reattachment in proximal humeral hemiarthroplasty

Hemiarthroplasty can be an effective treatment for 4-part fractures of the proximal humerus; however, results are often unpredictable. Proper surgical technique is critical for success. Reconstruction of the displaced tuberosities should attempt to impart maximal interfragmentary stability. To our knowledge, a comparison of different tuberosity reconstruction methods has not been reported. We evaluated 5 techniques of tuberosity reattachment on 8 humeri. Four-part fractures were simulated by an oscillating saw in fresh-frozen cadaveric shoulders. In the control construct, the greater and lesser tuberosities were attached to the humeral shaft with nylon strap ties (2.4 x l mm) applied at 9.1 N with closure of the rotator interval. Five anatomic reconstructions were then performed:(1) the control tuberosities were attached to each other with strap ties, and (2) the control tuberosities were attached to each other with strap ties, incorporating the anterior fin of the prosthesis. To each of these 3 constructs, a circumferential cerclage (4.8 x 1.25-mm strap tie) applied at 39.2 N was placed around the tuberosities and incorporated into the medial hole of the prosthesis (techniques 3, 4, and 5). Through use of a robot articulator at a rate of 10 degrees /s, passive external rotation from 0 degrees to 60 degrees was performed on the control and the 5 test constructs of each specimen. Interfragmentary displacement of the bony fragments was measured with mercury strain gauges and strain calculated. This strain was minimal and statistically less (P <.05) in those constructs in which a cerclage was used. Incorporation of the nylon strap into the fin of the prosthesis did not enhance stability. In those constructs in which a cerclage was used, maximal displacement was 0.14 +/- 0.7 mm (38% +/- 19% strain), as compared with 0.72 +/- 0.5 mm (204% +/- 133% strain) without it. Reconstruction of 4-part proximal humerus fractures with hemiarthroplasty should incorporate a circumferential medial cerclage. This will decrease interfragmentary motion and strain, maximize fracture stability, and facilitate postoperative rehabilitation.     

Primary hemiarthroplasty for treatment of proximal humeral fractures

BACKGROUND: Primary hemiarthroplasty of the shoulder is used to treat complex proximal humeral fractures, although the reported functional results following this method of treatment have varied widely. The aim of this study was to prospectively assess the prosthetic survival and functional outcomes in a large series of patients treated with shoulder hemiarthroplasty for a proximal humeral fracture. By determining the factors that affected the outcome, we also aimed to produce models that could be used clinically to estimate the functional outcome at one year following surgery. METHODS: A thirteen-year observational cohort study of 163 consecutive patients treated with hemiarthroplasty for a proximal humeral fracture was performed. Twenty-five patients died or were lost to follow-up in the first year after treatment, leaving 138 patients who had assessment of shoulder function with use of the modified Constant score at one year postinjury. RESULTS: The overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. The overall median modified Constant score was 64 points at one year, with a typically good score for pain relief (median, 15 points) and poorer scores, with a greater scatter of values, for function (median, 12 points), range of motion (median, 24 points), and muscle power (median, 14 points). Of the factors that were assessed immediately after the injury, only patient age, the presence of a neurological deficit, tobacco usage, and alcohol consumption were significantly predictive of the one-year Constant score (p < 0.05). Of the factors that were assessed at six weeks postinjury, those that predicted the one-year Constant score included the age of the patient, the presence of a persistent neurological deficit, the need for an early reoperation, the degree of displacement of the prosthetic head from the central axis of the glenoid seen radiographically, and the degree of displacement of the tuberosities seen radiographically. CONCLUSIONS: Primary shoulder hemiarthroplasty performed for the treatment of a proximal humeral fracture in medically fit and cooperative adults is associated with satisfactory prosthetic survival at an average of 6.3 years. Although the shoulder is usually free of pain following this procedure, the overall functional result, in terms of range of motion, function, and power, at one year varies. A good functional outcome can be anticipated for a younger individual who has no preoperative neurological deficit, no postoperative complications, and a satisfactory radiographic appearance of the shoulder at six weeks. The results are poorer in the larger group of elderly patients who undergo this procedure, especially if they have a neurological deficit, a postoperative complication requiring a reoperation, or an eccentrically located prosthesis with retracted tuberosities.     

Total shoulder arthroplasty versus hemiarthroplasty. Indications for glenoid resurfacing

The results of total shoulder arthroplasty and hemiarthroplasty in a similar patient population were compared in an effort to define more clearly the indications for resurfacing the glenoid. The results of 64 Neer hemiarthroplasties in 59 patients were compared with 146 Neer total shoulder arthroplasties in 134 patients in a retrospective review of the period between 1974 and 1986. The average follow-up period was 44 months (range, 24-124 months). Hemiarthroplasty and total shoulder arthroplasty produced similar results in terms of functional improvement. Pain relief, range of motion, and patient satisfaction were better with total shoulder arthroplasty than hemiarthroplasty in the rheumatoid population. Progressive glenoid loosening was found in 12% of total should arthroplasties but no correlation with pain relief or range of motion was noted. Total shoulder arthroplasty is recommended for patients with inflammatory arthropathies, and hemiarthroplasty is recommended for patients with osteoarthritis, avascular necrosis, and four-part fractures with preservation of glenoid congruity and absent synovitis.     

Shoulder hemiarthroplasty in the management of humeral head fractures

The results of hemiarthroplasty for shoulder fracture were evaluated in 26 patients, 20 women and 6 men with a mean age of 64.7 +/- 8.2 years. The follow-up period was 2 to 7 years. Cofield prostheses were used for the first 10 patients and subsequently 9 Global and 7 Aequalis prostheses were implanted, all cemented. The clinical outcome was assessed using the Constant-Murley scale. The mean score, at the last follow-up, was 70.4 +/- 16.4 (39-96). Mean forward elevation of the arm was 150 degrees (300-175 degrees), mean abduction was 145 degrees (30 degrees -170 degrees), and mean external rotation was 30 degrees (10 degrees-45 degrees). In most of the cases internal rotation corresponded with a position of the dorsum of the hand at the L3 vertebrae. The patients in our series achieved their optimal clinical result within the first 6 months after operation. Shoulder hemiarthroplasty is a worthwhile procedure, giving predictable results provided the patients have been carefully selected, the individual anatomy of the shoulder is restored and an aggressive rehabilitation program is implemented during the first six months after surgery.     

Four-part displaced proximal humeral fractures: treatment with hemiarthroplasty

Between 1996 and 2000 a total of 25 hemiarthroplasties of the shoulder in just as many patients were carried out. A total of 15 were followed-up (minimum 1 year, maximum 5 years, mean 2.5 years; mean age 75.5 years). The Constant score showed a mean of 73.26 points (with a maximum score of 90 and a minimum of 40). One patient obtained a reduced Constant score (40 points) because of severe lesions of the rotator cuff and continuous pain, even during the night. Patients reported that they were satisfied in 75% of cases. We believe that the integrity of the cuff is an essential condition for final success, alongside important indications such as type of fracture, bone quality, age and motivations of the patient, with respect for rules governing method of implantation and protocols for rehabilitation used.     

Inlay hemiarthroplasty of the humeral head for nontraumatic osteonecrosis

BackgroundOsteonecrosis of the humeral head often occurs in younger individuals and presents a difficult clinical situation. The purpose of this study was to evaluate the patient reported outcomes in patients undergoing inlay hemiarthroplasty for nontraumatic osteonecrosis of the humeral head. We hypothesized that patients would achieve a meaningful clinical improvement.MethodsA retrospective review of prospectively collected data on 9 patients undergoing inlay hemiarthroplasty for humeral head osteonecrosis was conducted. The American Shoulder and Elbow Surgeons Shoulder score (ASES), Simple Shoulder Test (SST), visual analog scale for pain (VAS), and range of motion measurements were collected preoperatively and at final follow-up. Radiographs were evaluated for any evidence of component loosening or glenoid wear. The primary outcome was achievement of substantial clinical benefit (SCB) for ASES.ResultsPostoperatively at a mean of 7.2 years the ASES improved from 35 to 73 (p = 0.011), the SST improved from 2 to 6 (p = 0.038), and the VAS for pain decreased from 7 to 3 (p = 0.009). Forward elevation increased from 96° to 138° (p = 0.012) and external rotation increased from 13° to 63° (p = 0.007). SCB for ASES was seen in 7 out of the 9 patients (78%). Asymptomatic mild or moderate glenoid wear was seen in 4/9 (44%) of patients. One patient (11%) developed symptomatic glenoid wear necessitating conversion to total shoulder arthroplasty.ConclusionInlay hemiarthroplasty offers a viable solution to osteonecrosis of the humeral head.Level of Evidence: Level IV; Treatment Study     

Functional outcome after proximal humeral fractures treated with hemiarthroplasty

Objective

To evaluate functional outcome after hemiarthroplasty for displaced proximal humeral fractures and to review whether prosthesis type, intraoperative technique or previous ipsilateral shoulder surgery could affect the outcome.

Methods

We reviewed the medical records and radiographs of patients who had undergone hemiarthroplasty for proximal humeral fractures between 1992 and 2000. We identified 45 patients, 39 with acute fractures and 6 with fracture-related complications. One surgeon performed 17 surgeries (38%), and the rest were carried out by 11 other orthopedic surgeons. Using the American Shoulder and Elbow Surgeons Evaluation Form and the Western Ontario Rotator Cuff Index, we evaluated patients who had been followed for at least 2 years for residual shoulder pain, range of motion, strength, stability and function. The senior authors reviewed the radiographs.

Results

The mean age of the patients at presentation was 70 (range 46–95) years. The mean active forward elevation was 87°, abduction 63° and external rotation 22°; the mean internal rotation was to the L2 vertebra. Of the patients, 15% reported severe pain, and 25% were unable to sleep on the affected side. Patients with previous surgeries and those with intraoperative cuff tears were found to have more postoperative pain.

Conclusion

We conclude that soft tissue status and operative technique play an important role in late postoperative pain and range of motion. Hemiarthroplasty after failed open reduction and internal fixation is associated with inferior results. We were unable to show a difference in long-term outcome related to the prosthesis type.     

Relevance of the restoration of humeral length and retroversion in hemiarthroplasty for humeral head fractures

Sixteen patients, with a fracture of the upper humerus treated with hemiarthroplasty, were followed-up for 45.7 +/- 15.1 (20-72) months after surgery. The results were assessed using the Constant-Murley scale. The mean score was 75.8 +/- 15.7 (54-96) points out of a possible maximum of 100. At the time of their last follow-up they underwent CT of the fractured and contralateral humerus. Humeral length and retroversion were measured and evaluated. A very good final outcome (Constant score more than 71) was achieved in patients with a difference in retroversion less than 10 degrees and a difference in length less than 14 mm, between fractured and sound humerus. The mean difference in retroversion was 8.7 degrees and the mean difference in length was 0.65 cm, between fractured and sound humerus. We attribute the very good clinical outcome in our series to the quality of the anatomical reconstruction that was performed.     

Shoulder hemiarthroplasty for the treatment of complex proximal humeral fractures

Objective: To investigate the indication, perioperative announcements, selection of prosthesis and clinical results of shoulder hemiarthroplasty for the treatment of complex proximal humeral fractures.Methods: A total of 55 patients who suffered from com-plex proximal humeral fractures were treated by shoulder hemiarthroplasty. The mean age was 55.6 years and mean follow-up period was 25.1 months. The scoring system modi-fication for hemiarthroplasty (SSMH) had been adopted for evaluation at the latest follow-up.Results: The pain was obviously relieved in all patients. Fifty patients were painless and 5 patients had slight pain. The mean range of motion was 100°(90°-110°) in abduction, 95°(80°-100°) in forward flexion, 35°(30°-40°) in extemal rotation and internal rotation was confined at L2 level (L1-L3). The mean SSMH score was 27.9 (24-29). Fifty patients (90.1%) were satisfied with the clinical outcome.Conclusions: Shoulder hemiarthroplasty is an effective method to treat complex proximal humeral fractures. The proper selection of patients and prosthesis, good operation skill and enough functional exercise are the key points of successful treatment.     

单纯人工肱骨头置换术治疗肱骨近端粉碎性骨折

目的探讨单纯人工肱骨头置换术治疗肱骨近端严重3～4部分骨折的方法及其效果。方法对本组12例肱骨近端粉碎性骨折患者进行了单纯人工肱骨头置换术,其中男5例,女7例,年龄42～67岁,平均（54．3±3．4）岁。按AO骨折分类标准,9例B2型骨折,2例B3型骨折,1例c3型骨折。结果术后随访9～36个月,平均17．2个月。采用Neer标准评定患者肩关节功能,其中4例大于90分,其余均在80分以上。结论对于肱骨近端粉碎性骨折而言,单纯人工肱骨头置换术是一种疗效较好的治疗方法,人工肱骨头假体安装和肱骨大、小结节解剖重建是提高人工肱骨头置换术疗效的关键,并且术中注意修复损伤的肩袖。术后需要求患者积极进行康复训练促进功能恢复。