Reverse shoulder prosthesis as revision surgery after fractures of the proximal humerus, treated initially by internal fixation or hemiarthroplasty

Complex (3–4 fragments) fractures of the proximal humerus often have a bad outcome, whatever treatment is performed. When revision surgery is required, reverse shoulder prosthesis can improve function and reduce pain in these patients. We analysed whether the choice of the first treatment (hemiarthroplasty vs. reduction and fixation) can influence the outcome of revision surgery. Our data demonstrate that results are not significantly dependent on the choice of the first implant, even though there is a tendency for patients with previous hemiarthroplasty to have a worse outcome.     

Reverse shoulder prosthesis as revision surgery after fractures of the proximal humerus,treated initially by internal fixation or hemiarthroplasty

Complex (3–4 fragments) fractures of the proximal humerus often have a bad outcome, whatever treatment is performed. When revision surgery is required, reverse shoulder prosthesis can improve function and reduce pain in these patients. We analysed whether the choice of the first treatment (hemiarthroplasty vs. reduction and fixation) can influence the outcome of revision surgery. Our data demonstrate that results are not significantly dependent on the choice of the first implant, even though there is a tendency for patients with previous hemiarthroplasty to have a worse outcome.     

肱骨近端骨折肱骨头置换假体高度的控制

目的:评估利用大结节骨折片复位的方法,确定肱骨近端骨折肱骨头置换假体高度的临床疗效。方法:回顾性研究2015年1月至2019年12月收治并获得随访的肱骨近端骨折患者,符合肱骨头置换指征19例,男7例,女12例;左侧8例,右侧11例;年龄58~84(71.5±5.8)岁;受伤至手术时间3~18(7.9±4.3) d。根据Neer分型,3部分骨折伴脱位2例,4部分骨折17例,其中伴肱骨头脱位6例,肱骨头劈裂2例。19例采用组配式肱骨头假体,在手术过程中,试复位肱骨大结节骨折块,确定肱骨大结节顶点到肱骨标记点的距离,以此距离作为假体高度的标准。术后1年采用Constant-Murley评分,美国加州大学洛杉矶分校(University of California,Los Angeles,UCLA)肩关节评分评价肩关节功能状况及患者满意度。结果:19例均获随访,时间12~58(31.9±14.2)个月。测量手术后上臂长度26~32 cm,双侧比较误差<0.5 cm。术后3个月肩关节正侧位X线片示骨折均愈合。术后1年Constant-Murley评分(80.8±8.9)分,UCLA评分(27.9±4.8)分。术后1年患者满意度89.5%(17/19)。结论:肱骨近端骨折肱骨头假体置换手术过程中,试复位肱骨大结节骨折块,确定肱骨大结节顶点到肱骨标记点的距离,以此距离确定假体高度,方法简单准确,临床效果良好。     

Surgical treatment for acute and displaced proximal humerus fractures in elderly patients: hemiarthroplasty vs. reverse shoulder arthroplasty

BackgroundProximal humerus fractures (PHFs) are the third most common fractures in elderly patients. The best treatment option on this population is still a topic of discussion. Reverse shoulder arthroplasty (RSA) has increased popularity as a viable treatment option for these fractures. Yet, few studies demonstrate the risk factors for mortality after this procedure.MethodsThe authors present a retrospective study including patients older than 75 y with acute and displaced PHFs primarily treated with RSA or hemiarthroplasty in a public hospital between January 2004 and January 2020. The exclusion criteria were pathologic fractures and more than 6 weeks to surgery. Survival curves were obtained using the Kaplan-Meier method and the log-rank test was performed to compare survival rates.ResultsA total of 73 patients met the inclusion criteria. The mean age at the time of fracture and surgery was 78 y old, 10 males and 63 females, with a median clinical follow-up of 64 months (standard deviation 34). Forty-one patients (56%) had an American Society of Anesthesiologists score of 2. Twenty-eight patients were submitted to hemiarthroplasty and 45 to RSA. Regarding hemiarthroplasty, only one patient with hemiarthroplasty died within a year, and the 5 y survival rate was 70%. Concerning to RSA group, five patients died within a year, and the survival rate at 5 y was 66.2 %. The American Society of Anesthesiologists score (P < .001) was the only risk factor identified for mortality at 5 y. Hemiarthroplasties had more prosthetic loosening compared with RSA (P = .024). Three hemiarthroplasties were converted to RSA, and we verified 1 RSA infection. In the group of hemiarthroplasties, 56% returned to their normal daily living activities, while in the RSA 92% did that, representing a significant difference (P = .007).ConclusionRSA as a primary treatment for displaced PHFs had a high survival rate (88.9% at 1 year and 66.2% at 5 y) and better functional results comparing to patients treated with hemiarthroplasty. With proper patient selection, RSA is a safe procedure for the treatment of PHF, especially in an elderly population.     

Outcome of cemented Neer II hemiarthroplasty in displaced humeral head fractures

The functional and radiological outcome of cemented Neer II hemiarthroplasty performed within six weeks after a fracture-dislocation or a three/four-part humeral head fracture was evaluated in 48 patients with an average age of 73 years (range: 45 to 89), with an average follow-up period of 44 months (range: 6 to 106). Thirty-two (67%) patients were satisfied or very satisfied. Twenty-nine (61%) patients had no or mild pain, 17 (35%) had moderate pain and two (4%) had severe pain. Constant Score averaged 49 (range: 8 to 71) compared to 78 (range: 40 to 100) for the nonoperated shoulder (p < 0.001). The 26 (57%) patients with abnormal radiographs (malpositioning or loosening of the prosthesis, non-union of tuberosities, heterotopic ossification, and/or glenoid erosion) had a significantly lower Constant Score (45 [range: 8 to 69] versus 55 [range: 31 to 71], p = 0.013). The functional outcome is disappointing and related to the radiographic status. The patients however seem to be satisfied despite a rather stiff shoulder and in our opinion a non-acceptable pain relief.     

Treatment of comminuted proximal humerus fractures with shoulder hemiarthroplasty in elderly patients

This retrospective study was done to find out the outcome of hemiarthroplasty of the shoulder following comminuted proximal humeral fractures in 20 elderly patients. Their average age was 77.6 years. The average follow-up was 33 months. All patients were reviewed in the outpatient clinic using the Constant Score. The median Constant Score was 47.5. None of the patients had severe pain. Four had moderate and 16 had no or mild pain. Range of movement was not good. The activities of daily living were significantly reduced in patients with moderate shoulder pain. Sixteen patients (80%) were satisfied with the outcome of the management of their shoulder injury. Radiological assessment showed malrotation of the prosthesis and ectopic ossification in one patient each. Osteolysis around the greater tuberosity was noted with three isoelastic prostheses. Seven patients showed proximal migration of the prosthesis although there was no significant difference in functional results. Complications included fatal pulmonary embolism in one patient. Overall, hemiarthroplasty of the shoulder gave good pain relief but there was only moderate functional improvement.     

Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus

The purpose of this study was to evaluate the results of hemiarthroplasty for displaced proximal humeral fractures and to assess clinical and radiologic parameters that could explain unsatisfactory results. Sixty-six consecutive patients (45 women and 21 men) with a mean age of 66 years (range, 31-85 years) were followed up postoperatively for a mean of 27 months (range, 18-59 months), both clinically and radiologically. Subjectively, 29 patients were very satisfied, 9 were satisfied, and 28 were unsatisfied. Postoperative active elevation averaged 101 degrees +/- 33 degrees, external rotation averaged 18 degrees +/- 15 degrees, and internal rotation averaged the L3 level (+/-3 vertebrae). The absolute Constant score averaged 56 of 100 points (range, 20-95 points). Initial tuberosity malposition was present in 18 patients (27%). Tuberosity detachment and migration were noted in 15 patients (23%). Tuberosity migration could be observed after initial tuberosity malpositioning, as well as after initial correct positioning. Final tuberosity malposition occurred in 33 patients (50%) and correlated with an unsatisfactory result, superior migration of the prosthesis, stiffness or weakness, and persistent pain. Factors associated with failure of tuberosity osteosynthesis were poor initial position of the prosthesis (specifically, excessive height and/or retroversion), poor position of the greater tuberosity, and women over age 75 years (likely with osteopenic bone). Techniques to improve tuberosity osteosynthesis, including modifications to current prosthetic design and instrumentation to allow for a more anatomic reconstruction, should lead to more predictable and satisfactory results.     

肱骨近端四部分骨折假体置换术中结节复位程度对肩关节力学平衡的影响

目的通过生物力学测试,评估肱骨近端四部分骨折术后结节复位程度对肩关节力学平衡的影响。方法新鲜国人肩关节标本4具,先测定记录其正常情况下外展、外旋等力学数据,定为正常组。然后将标本造成肱骨近端四部分骨折模型,随机分为2组进行人工肱骨头置换术,1组为大、小结节解剖复位,另1组为大、小结节未能解剖复位。在标本肱骨头大、小结节处布置T型应变片,测量肩关节置换术前、后在不同功能位时结节处的应力强度变化,并在冈下肌、肩胛下肌布置软组织韧带型桥式应变型传感器,测量不同功能位时肩关节的肌张力。结果结节解剖复位时其轴向刚度和水平剪切刚度高于正常对照组2％～4％,但差异无显著性（P〉0．05）;处于非解剖位时则低于正常对照组26％-41％,差异有显著性（P〈0．05）。轴向刚度随外展角度的增加而减少,水平剪切刚度则不断增加。结论手术中肱骨大小结节复位程度十分重要,否则会引起假体刚度削弱、位移扩大、脱位率增加,影响术后肩关节功能的恢复。术后结节的强度因假体位置而变化,并随着肱骨外展0—90°及内、外旋变化而变化。     

Aequalis骨折型肩关节假体治疗严重肱骨近端骨折的初步报告

肱骨近端骨折目前多主张切开复位内固定治疗,但对于严重的Neeg三、四部分肱骨近端骨折,部分患者术后疗效欠佳,且易发生肱骨头缺血性坏死等并发症[1].人工肩关节置换术是治疗严重肱骨近端骨折的一个重要方法,能够有效消除患肩的疼痛,但是有些患者术后患肩功能的恢复并不理想[2].研究证实肩关节假体的位置、结节固定的稳定性、肩袖损伤以及骨折类型是影响人工肩关节置换术治疗肱骨近端骨折临床效果的重要因素[3].     

Functional outcome of shoulder hemiarthroplasty for fractures: A multicentre analysis

In this multicentre study, data on 102 shoulder hemiarthroplasties for the treatment of fractures were analysed retrospectively with regard to tuberosity healing and functional outcome.

Methods

Clinical outcome was assessed using the constant score (CS) and the American Shoulder and Elbow Score (ASES). The mean follow-up time was 28.1 months. The proportion of patients presenting tuberosity healing was 35.3% (36 out of 102).

Results

Anatomical tuberosity healing has a significant effect on CS, especially for lateral elevation (p = 0.0076), forward elevation (p = 0.0002), power (p = 0.0023) and the ASES (p = 0.017). However, the pain value of the CS was not influenced by tuberosity healing (p = 0.34). In patients with anatomically healed tuberosities, the CS averaged 53.0 points, whereas in the group of patients with non-anatomical tuberosity healing, the score averaged 40.1 points (p = 0.0004).There was an 11-fold increase in tuberosity nonunion in females compared with males (p = 0.0045). Further, nonunion was seen to be associated with advanced age of >70 years (p = 0.037) and the presence of osteoporosis (p = 0.034).

Conclusion

In this study, we found that anatomical tuberosity healing around the prosthesis improved functional outcome and range of motion.     

Results of shoulder hemiarthroplasty in patients with acute and old fractures of the proximal humerus]

STUDY-DESIGN: We report on a prospective study of 22 patients after shoulder hemiarthroplasty in acute and old proximal humerus fractures. METHOD: Nine patients with an acute and 13 with an old humerus fracture, in whom a hemiarthroplasty was performed have been evaluated clinically using the Constant score as well as radiologically on average 22 months postoperatively. RESULTS: The mean Constant score improved on 28 points (27 to 55). The improvement was especially distinct in the group with acute fractures. Sixteen of the twenty examined patients were painfree. Two patients reported sleeping disturbances due to pain. The ROM was improved, especially in forward elevation and abduction. In two patients with an old fracture the results were less satisfying. Major complications could not be observed. In five cases X-ray revealed an atrophy of the fixated fragments. Dislocations did not occur. Radiological changes of the glenoid, already seen preoperatively became more obvious. Some humeral components, inserted without cement, showed "densification lines". There were no clinical signs of loosening. CONCLUSION: By performing hemiarthroplasty pain relief can be achieved, especially in old fractures. The postoperatively achieved joint function mainly depends on the type of fracture as well as ist age. In cases with a destroyed glenoid we now prefer to perform a total arthroplasty. In our opinion, general cement use for shaft fixation is not necessary.     

Position of shoulder arthroplasty and clinical outcome in proximal humerus fractures

Four-part proximal humeral fractures are frequently treated with shoulder replacement. Outcome of this procedure has not been standardized, and there are controversy data on range of motion (ROM) and active function of the shoulder. The aim of this study is to compare shoulder prosthesis position (SPP) in terms of version of humeral head and height of stem with clinical subjective and objective outcome. Fifty patients were treated with shoulder hemiarthroplasty for four-part proximal humeral fracture or fracture-dislocation of the humeral head. Radiological examination and CT-scan were performed preoperatively and at follow-up. Clinical outcome evaluation included active and passive ROM, and subjective perspective collected through SF-36, OSQ, ASES, and DASH. No significant correlation between stem height and clinical outcome were found. The prosthesis version correlates with all subjective questionnaires. The ROM was not correlated with stem height and prosthesis version. SPP involves clinical outcome, with great relevance of implant version.     

Position of shoulder arthroplasty and clinical outcome in proximal humerus fractures

Four-part proximal humeral fractures are frequently treated with shoulder replacement. Outcome of this procedure has not been standardized, and there are controversy data on range of motion (ROM) and active function of the shoulder. The aim of this study is to compare shoulder prosthesis position (SPP) in terms of version of humeral head and height of stem with clinical subjective and objective outcome. Fifty patients were treated with shoulder hemiarthroplasty for four-part proximal humeral fracture or fracture-dislocation of the humeral head. Radiological examination and CT-scan were performed preoperatively and at follow-up. Clinical outcome evaluation included active and passive ROM, and subjective perspective collected through SF-36, OSQ, ASES, and DASH. No significant correlation between stem height and clinical outcome were found. The prosthesis version correlates with all subjective questionnaires. The ROM was not correlated with stem height and prosthesis version. SPP involves clinical outcome, with great relevance of implant version.     

Neurovascular complications and functional outcome in displaced supracondylar fractures of the humerus in children

We retrospectively studied the complications associated with a displaced supracondylar fracture of the humerus in children and its treatment. Between 1978 and 1997, 200 displaced fractures were treated by operative means. In 190 cases closed reduction and percutaneous pinning was performed. In 10 cases vascular impairment or unsatisfactory reduction necessitated open exploration. Functional and cosmetic success was achieved in 90% of all operated children. In 33 (16.5%) of all cases we found neurological impairment. All recovered without sequelae, except for one case with persistent radial nerve palsy which recovered after a sural nerve interposition graft. Transient neurological problems are common in this fracture. A mini-open procedure is recommended for the ulnar Kirschner wire (K-wire) to prevent iatrogenic ulnar nerve injury.     

Shoulder hemiarthroplasty for fractures of the proximal humerus

Scaphoid fractures are uncommon in children, but if maltreated, they can result in nonunion. The authors report a case of left scaphoid nonunion in an 11-year-old boy. The operative management of this pseudarthrosis was performed (K-wire fixation and bone grafting of scaphoid). After a 10-month follow-up period, the left wrist regained a full range of motion with no impairment. The roentgenograms showed union of the scaphoid. Surgical management of scaphoid nonunion fractures in children offers successful fusion, with very low nonunion rate and patient’s satisfaction.     

Shoulder hemiarthroplasty for fractures of the proximal humerus

Proximal humeral fractures were managed with primary hemiarthroplasty in 57 patients, 53 women (93%) and 4 men (7%) aged 51-87 years (mean 72.2). The mean follow-up period was 52 months (range 12-98), and the mean Constant score was 59.2 (range 38-76). Patients were very satisfied (n = 19); satisfied (n = 32) or dissatisfied with the outcome (n = 5). One patient required early revision surgery. Surgical treatment of three- and four-part fractures of the proximal humerus with hemiarthroplasty is a safe and effective approach, the outcome of which appears to be related to the quality of the anatomical reconstruction of the tuberosities.     

人工肱骨头置换治疗老年肱骨近端粉碎性骨折

目的探讨人工肱骨头置换治疗老年肱骨近端粉碎性骨折的临床疗效。方法采用人工肱骨头置换治疗16例老年肱骨近端粉碎性骨折患者。结果患者均获随访,时间10～37个月。末次随访时ASES评分为64～94(89.1±4.5)分;Constant评分为53～95(85.7±7.2)分;VAS评分为0～5(2.7±0.6)。肩关节活动度前屈上举为90°～150°(128.1°±8.4°),外展为50°～120°(85°±10.5°),外旋为30°～40°(35.0°±2.3°),内旋为L2～T10水平。患者对于疼痛的满意度为93.8%(15/16),功能恢复的满意度为87.5%(14/16)。结论严格掌握手术适应证,选择良好的手术时机,规范缜密的手术计划及操作,术后长期、完善的康复治疗,应用人工肱骨头置换治疗老年肱骨近端粉碎性骨折可获得满意的效果。     

人工肱骨头置换治疗老年肱骨近端骨折

目的探讨应用人工肱骨头置换治疗老年肱骨近端骨折的疗效.方法自2000年3月～2003年3月采用三角肌、胸大肌间隙入路行人工肱骨头置换术治疗老年肱骨近端骨折21例,男10例,女11例;年龄62～82岁,平均72.3岁.根据Neer分类,三部分骨折6例,四部分骨折13例,肱骨头劈裂骨折2例.新鲜骨折(受伤后2周内)18例,陈旧骨折3例.术后患肢用三角巾悬吊,第2 d拔除引流管并开始行肩部肌肉收缩锻炼,第3 d行肩关节被动和辅助下主动的适量外旋和前屈活动,从20°开始,每天增加5°～8°.1周后可在健侧手臂辅助下加大肩关节运动幅度,每天3～4次,每次10～15min,要避免引起疼痛和拉伤关节.术后6周内避免肩关节过度主动屈曲和外展,6周后去除三角巾,加强主动功能锻炼.结果手术时间40～80 min,平均60 min,出血量200～300ml.术后随访6～36个月,平均14.6个月.所有患者均无感染、神经损伤和假体周围骨折,无假体松动、脱位等并发症.按照SSMH综合评分标准所有患者平均为24.5分,27分以上(优)3例,24～27分(良)14例,14～24分(中)3例,低于14分(差)1例,优良率为86%;21例患者疼痛评分平均为9.3分,功能评分为8.6分,肌力和运动评分为8.2分,术后肩关节活动范围上举为91.6°±7.2°,外旋63°±5.5°,内旋76.6°±2.2°.结论人工肱骨头置换术是治疗老年肱骨近端骨折较满意的方法,手术时间相对较短,术后功能恢复快,能有效减轻肩关节疼痛.但人工肱骨头置换术可能存在中晚期并发症,对于年轻患者的疗效仍有待于进一步研究.