Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

PurposeUnsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.MethodsWe include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.ResultsOf 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).ConclusionSuccessful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.     

Trabecular metal™ shoulder prosthesis in the treatment of complex proximal humeral fractures

Purpose

Shoulder arthroplasty is one of the options for the treatment of complex proximal humeral fractures. The purpose of this study was to assess the clinical and radiographic results of the trabecular metal shoulder prosthesis in the treatment of complex proximal humeral fractures.

Methods

Fifty-one consecutive patients with complex proximal humeral fractures who underwent primary shoulder arthroplasties with the trabecular metal? prosthesis were enrolled in this study. At the final follow-up appointment, 42 of the patients (82.4 % of the total patients enrolled) were available for both clinical and radiographic evaluation. There were 28 women and 14 men with a mean age of 65.4?±?10.7 years. The dominant arm was involved in 30 of the cases. According to Neer’s classification, there were seven three-part fractures, 27 four-part fractures and eight head-splitting fractures. Additionally, there were 37 hemiarthroplasties and five total shoulder arthroplasties.

Results

After a mean follow-up of 37.0?±?8.4 months (range 24–52 months), the average ranges of motion were: 38.6?±?15.0° for external rotation, L3 level for internal rotation and 132.3?±?36.0° for forward elevation. The mean American Shoulder and Elbow Surgeons, visual analogue scale and University of California, Los Angeles scores were 82.1?±?14.1, 0.4?±?1.1 and 28.8?±?5.1, respectively. The post-operative radiographs exhibited an anatomically attached greater tuberosity in 39 of the 42 shoulders. Of the three patients with greater tuberosity complications, as displayed by their radiographs, two were observed with malpositioned tuberosities, while the other greater tuberosity was resorbed. Proximal migration of the prosthesis was observed in all three shoulders with greater tuberosity complications and in two shoulders with an anatomically attached greater tuberosity. No neurovascular injury, infection or prosthetic loosening was identified during the final follow-up appointments.

Conclusions

Satisfactory results can be expected with the trabecular metal shoulder prosthesis for the treatment of complex proximal humeral fractures. The post-operative radiographs demonstrated an anatomically healed greater tuberosity in 93 % of the patients at a minimum follow-up time of two years.     

Reverse shoulder prosthesis for acute four-part fracture: tuberosity fixation using a horseshoe graft

Results of hemiarthroplasty for complex four-part proximal humerus fractures in the elderly have been unreliable. Although patients often achieve pain relief, return of above-shoulder level function can be challenging, because tuberosity nonunion, malunion, and/or resorption is quite common. The reverse shoulder replacement has been advocated as a reliable alternative for these patients. Preliminary studies have suggested that tuberosity healing is critical for achieving external rotation strength after reverse shoulder arthroplasty. We describe a technique of tuberosity repair using a wedge horseshoe graft, which can provide improved surface area for tuberosity healing. A clinical series of seven patients treated with this technique is reported with a minimum follow-up of 12 months (range, 12-23 months). The tuberosity union rate was 86% (six of seven patients). Average active forward elevation was 117° (range, 95°-150°), and active external rotation was 19° (range 0°-30°). Visual analog scale pain scores averaged 0.6 (range, 0-1), visual analog scale function averaged 8.7 (range, 7-10), mean American Shoulder and Elbow Surgeons pain was 47.1 (range, 45-50), and mean American Shoulder and Elbow Surgeons function was 39.2 (range, 31-50). Subjective satisfaction ratings were excellent for four patients, and good for two, and satisfactory for one. No patients were unsatisfied with their outcomes. The horseshoe graft technique provides a reliable means for anatomic restoration of the tuberosities, facilitating the return of shoulder function in elderly patients with complex four-part proximal humerus fractures treated with a reverse total shoulder.     

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

IntroductionA stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures.Patients and methodsRetrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value.ResultsAfter a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported.DiscussionArthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.     

Shoulder hemiarthroplasty for the treatment of three and four part fractures of the proximal humerus using Comprehensive? Fracture stem

We looked at the functional outcome of 32 consecutive patients with proximal humeral fractures that required hemiarthroplasty. Functional status was assessed using University of California Los Angeles (UCLA) shoulder end result assessment, simple shoulder test (SST) and American Shoulder and Elbow Society (ASES) shoulder index. Mean age of the patients was 72.2 years and the mean follow-up was 25.3 months. The mean score on UCLA shoulder end result assessment was 24.8, the mean SST score was 7.4 and the mean ASES shoulder index was 67.2. Mean active forward elevation was 85.1°. Patient satisfaction was around 81%. Radiologically, no dislocation, loosening or greater tuberosity pull off was seen. Superior migration of the humeral head was seen in 11 patients (34%). There was no significant difference seen in functional outcome among different genders, age and those who had radiological superior migration of the prosthesis. However, there was a significant statistical difference seen in the functional outcome between patients who had a deficient or a good quality cuff showing that quality of the rotator cuff is an important predicator of functional outcome.     

Stemless and stemmed total shoulder arthroplasty: a comparison of short-term clinical and radiographic outcomes

BackgroundStemless total shoulder arthroplasty could provide benefits over stemmed arthroplasty which has represented the gold standard for decades. Proposed benefits of stemless arthroplasty include better reproduction of anatomy and reduction in stress shielding; however, this does not appear to be confirmed by any study. The hypothesis was there would be no clinical differences between the stemless and the short-stem prosthesis, but the stemless prosthesis would better reproduce coronal radiographic anatomy and have less radiographic evidence of stress shielding.Materials and MethodsA prospectively collected data of patients undergoing primary, anatomic total shoulder arthroplasty for osteoarthritis were retrospectively reviewed. Patient-determined outcomes including the Western Ontario Osteoarthritis Index, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Shoulder Activity Level were recorded preoperatively, at 1 year, and at 2 years. Preoperative and 1-year postoperative range of motion was recorded. Radiographic parameters to assess restoration of proximal humeral anatomy included humeral head height, humeral neck angle, humeral centering on the glenoid, and postoperative restoration of the anatomic center of rotation. Final postoperative radiographs were assessed for evidence of stress shielding.ResultsForty-eight patients had a stemmed humeral prosthesis, and 109 patients had a stemless prosthesis. Patient-determined outcomes were available from 2 years postoperatively in 99.4%. Both groups had significant improvements in all patient-reported outcomes and range-of-motion metrics, but there were no differences between the stemless and stemmed groups in these outcomes. The prosthetic humeral head of the stemmed components was more likely to extend further superior to the humeral osseous margin than that of the stemless group (2.0 ± 2.4 vs. 0.8 ± 1.4 mm; P = .0004). The stemless group had a smaller postoperative deviation from the anatomic center of rotation than the stemmed group (2.5 ± 1.9 vs. 3.2 ± 2.1 mm; P = .04). The humeral neck angle was comparable between the stemmed group and the stemless group (133 ± 7° vs. 131 ± 8°; P = .06). There was similar mean deviation of humeral head centering on the glenoid prosthesis between the stemmed and stemless groups (1.9 ± 1.8 vs. 1.6 ± 1.7 mm; P = .20). There was evidence of stress shielding in 10 patients (21%) with a stemmed prosthesis and in no patients with a stemless prosthesis at 1-year follow-up (P < .0001).ConclusionsThere were no differences in patient-determined outcomes between the groups at 2-year follow-up. Restoration of proximal humeral anatomy was either better or equivalent with the stemless prosthesis compared to the stemmed one. Radiographic evidence of stress shielding was found in the stemmed prosthesis but not in the stemless prosthesis at 1-year follow-up.     

Reverse total shoulder arthroplasty with a custom deltoid lateralization sleeve for the treatment of failed arthroplasty and severe proximal humeral bone loss

IntroductionReverse total shoulder arthroplasty (RTSA) is reportedly an effective option in the treatment of glenohumeral arthritis and severe comminuted proximal humeral fractures. To date, RTSA failures and their subsequent revisions are significant issues that have not been well studied. In revision RTSA cases with severe proximal humeral bone loss (PHBL), there is increased risk of early failure [4,10,28,30]. In this series, the authors evaluate the short-term results of a novel custom-made, patient-specific Deltoid Lateralization Sleeve (DLS) with an adjustable humeral RTSA component for revision of failed arthroplasty with severe bone loss.MethodsPatients treated with a custom, adjustable DLS system for revision RTSA between 2012 and 2019 at one institution were identified using medical health records and included in the study. Each patient had undergone multiple previously failed surgeries before the current salvage procedure was performed. Revision RTSAs with less than 5 centimeters (cm) of bone loss, precluding DLS use, were excluded. Data was retrospectively collected and included demographics, surgical history, amount of bone loss in centimeters, preoperative and postoperative range of motion (ROM), patient-reported outcome scores, and postoperative complications.ResultsFrom 2012 to 2019, 15 patients with a mean PHBL of 8.3 cm (range 5-12.5 cm) underwent revision RTSA with DLS. Median age was 66.0 years (range 25-81 years). Median clinical and radiographic follow-up was 30 months (range: 23-77 months). Median preoperative active anterior elevation (AE), active external rotation, and active internal rotation improved from 10° to 120°, 0° to 35°, and 0° to 40°, respectively. Median Visual Analog Scale pain score improved from 5 to 0, American Shoulder and Elbow Surgeons score improved from 25 to 65, Simple Shoulder Test score improved from 0 to 46, and Single Assessment Numeric Evaluation (SANE) score improved from 20% to 68%. There were 9 (60%) complications, including 5 major complications requiring revision surgery (33.3%). One patient (6.7%) was lost to follow-up.Discussion/ConclusionRevision RTSA for excessive PHBL with severe tuberosity deficiency can be surgically challenging. Irrespective of the high complication rate, DLS use in patients with severe PHBL and severe tuberosity deficiency may provide favorable long-term glenohumeral reconstruction viability.Level of evidenceLevel IV.     

Clinical outcomes of shoulder arthroplasty for post-instability arthropathy after open anterior bone block stabilization

BackgroundPost-instability glenohumeral arthropathy can occur after nonanatomic instability repairs. With advanced secondary arthritis, subsequent shoulder arthroplasty may be complicated by altered surgical anatomy, poor range of motion, subscapularis deficiency, unique glenoid wear patterns, and/or aberrant neurovascular anatomy. The purpose of this study was to evaluate the clinical outcomes of patients undergoing shoulder arthroplasty after previous open nonanatomic anterior shoulder stabilization, particularly glenoid bone block procedures.MethodsBetween 2008 and 2014, all patients with shoulder arthroplasty for symptomatic post-instability glenohumeral arthropathy after prior open stabilizations were identified from surgical case logs of two senior shoulder surgeons. Demographic variables were extracted from electronic medical records, operative reports, and preoperative and postoperative radiographs, and a minimum 24-month follow-up with completion of patient-reported questionnaires was required. Postoperative active forward elevation and active external rotation were recorded. The primary outcome measures were the visual analog scale for pain, American Shoulder and Elbow Surgeons Shoulder score, and the Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were extracted.ResultsA total of 12 patients were identified with an average age of 63 ± 12 years (range, 46-83), including 7 males and 5 females, and index surgery included open Bristow (n = 7), open Latarjet (n = 2), iliac crest bone graft (n = 1), and Putti-Platt procedure (n = 2). Seven patients underwent anatomic TSA, 4 reverse TSA, and 1 hemiarthroplasty. At an average of 44 ± 21 months follow-up, average active forward elevation and active external rotation improved from 100 ± 36 preoperatively to 132 ± 41 (P = .12) postoperatively and 19 ± 15 to 49 ± 11 (P < .01), respectively. The average visual analog scale decreased from 5 ± 3 to 1 ± 2 (P < .01) and mean American Shoulder and Elbow Surgeons improved from 44 ± 23 to 79 ± 17 (P < .01); and the average Simple Shoulder Test improved from 4 ± 2 to 9 ± 3 (P < .01). No perioperative complications or secondary reoperations were required, and only one patient experienced subsequent instability due to subsequent shoulder trauma.ConclusionDespite the surgical complexity and unique challenges associated with post-instability arthropathy, shoulder arthroplasty after prior open anterior bone block procedure or nonanatomic reconstruction is a safe procedure with low risk of perioperative complication, subsequent shoulder instability, or secondary revision surgery. All patients experienced significant improvements in pain, range of motion, and self-reported function at short- to mid-term follow-up.     

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.     

Intermediate to long term results of stemless metaphyseal reverse shoulder arthroplasty: A five to nine year follow-up

BackgroundShoulder arthroplasty incidence is increasing as is the volume of revision surgeries. Revision surgery is easier if humeral bone stock is preserved with minimal bone defects and osteolysis. This has led to an increased focus on the development of various short stemmed and stemless implants which provides stable fixation whilst preserving humeral bone stock.PurposeTo review the medium to long term clinical and radiological outcomes, complications and survival rates of a stemless reverse shoulder prosthesis.Patients and methodPatients with a minimum follow-up of 60 months following a reverse stemless shoulder arthroplasty were deemed eligible. Clinical and radiological data on twenty-one patients operated between 2009 and 2014 were recorded prospectively. Survivorship and patient recorded symptoms with the end point of revision surgery were recorded.ResultsMean follow-up of 78 months (60–114 months). Mean range of active elevation was 136° (80–170°). Mean range of active abduction and active external rotation was 122° (70–170°) and 47° (10–75°) respectively. Mean Oxford score improved from 12 pre-operatively to 44 at final follow up (p < 0.0001). Mean Constant Murley Score improved from 18 to 72 (p < 0.0001). Mean ADLEIR score of 13 pre-operatively increased to 32 post-operatively (p < 0.0001). Notching was seen in 23.5% of cases and no radiolucent areas were observed around the glenoid component. There were two cases of post traumatic peri-prosthetic fractures that were managed conservatively and one case of deep-seated infection that required a washout. The survivorship at the most recent follow-up was 100%.ConclusionThe advantages of bone preservation with the stemless metaphyseal prosthesis combined with encouraging medium to long term clinical and radiological results are very promising, particularly with the improved post-operative patient satisfaction scores. This is the first study that reports the results with a minimum of 5 year follow-up and has the longest mean follow-up period.Clinical relevanceThe reverse stemless shoulder prosthesis is an effective and reliable option for elective shoulder arthroplasty.     

Open reduction internal fixation vs. reverse shoulder arthroplasty for the treatment of acute displaced proximal humerus fractures

BackgroundProximal humerus fractures are a frequent fragility fracture in the aging population and represent a challenge to the orthopedic surgeon. Open reduction internal fixation (ORIF) of these fractures is viable but technically challenging and associated with a high complication rate. Recently, reverse shoulder arthroplasty (RTSA) with tuberosity repair has become a popular and successful option for treating these fractures. The purpose of this study is to compare outcomes of ORIF and RTSA for treatment of proximal humerus fractures.MethodsAn age-matched group of 50 patients treated with ORIF (25) and RTSA (25) were assessed at an average follow-up of 4.4 years. American Shoulder and Elbow Surgeons score (ASES) and Simple Shoulder Test (SST), radiographs, range of motion, and complications were evaluated between the two groups.ResultsThe reoperation rate and major complications were higher in the ORIF group compared to RTSA. No major complications were observed in the RTSA group. Forward flexion in the RTSA patients (143.2 ± 23.1) was shown to be significantly greater than ORIF patients (121.4 ± 35.1) (p= 0.0125) but no significant differences were observed for shoulder external rotation or internal rotation. There was no difference in ASES and SST scores between groups.ConclusionThe current study demonstrates good clinical outcomes for both RTSA and ORIF. However, reoperation rate was higher with ORIF with locked plating compared to RTSA for fracture with tuberosity repair in an age matched population. RTSA may be a better treatment option than ORIF for 3- and 4-part fractures in patients older than 65.Level of evidenceLevel III     

A retrospective analysis of complex proximal humerus fractures managed with reverse shoulder arthroplasty in a level 1 trauma center

BackgroundThe treatment of complex 3- and 4-part proximal humerus fractures (PHFs) in the elderly poses significant challenges because of osteoporosis and fracture comminution. The wide range of surgical options available is evidence of the complex nature of the injury. At present, reverse shoulder replacement is gaining popularity among shoulder surgeons for treating these difficult fractures, and the literature has shown equivalent or superior outcomes with reverse shoulder arthroplasty (RSA). We aimed to analyze the long-term results of these complex PHF treated with reverse shoulder replacement.MethodsFor this study, fractures from 39 patients with a mean age of 63.18 years who were treated with RSA for acute complex fractures of the proximal humerus in our institution between 2013 and 2019 were analyzed (n = 31, acute 4-part fractures; n = 4, acute fracture–dislocation; n = 3, fracture with irreparable cuff tear; n = 1, osteoporotic 2-part fracture). All patients had a standard reverse shoulder replacement (cemented humeral stem n = 37 and uncemented stem n = 2) surgery in a level 1 trauma center. The mean follow-up duration was 60 months (24-111 months). The clinical outcomes (Oxford Shoulder Score and Constant Shoulder Score) and the complications at 6 months, 12 months, and 24 months were analyzed.ResultsOur study found a relatively younger population, with 21 patients (53.84%) aged <66 years. Spearman's correlation showed that younger patients had better signs of improvement in Oxford Shoulder Scores at 2 years (P = .008). The average Oxford Shoulder Score was 39.12 ± 4.327, and the average Constant Shoulder Score was 67.67 on the operated side. The mean active forward elevation was 142.56 ± 22.29º, abduction was 136.538 ± 24.31º, external rotation was 27 ± 9.011º, and internal rotation was 33 ± 20.41º. The overall complication rate of 17.94% (periprosthetic infection n = 2, periprosthetic humerus fracture n = 1, and hematoma evacuation n = 4) in our study was similar to those of recent studies in the literature.ConclusionRSA provides a reliable option for PHFs and offers good results in the form of pain relief and good functional outcomes at 2 years even in a younger age group. Thus, it is fast becoming an important option in treating complex PHF, but we must be wary of the steep learning curve and the complications pertinent to this procedure.     

Minimally invasive plate osteosynthesis with locking plate for metastatic humeral fractures

BackgroundLimited reports have examined the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) with a locking plate (LP) in metastatic humeral fractures. Therefore, this study aimed to evaluate the effectiveness of MIPO in the treatment of metastatic humeral fractures.MethodsPatients who underwent MIPO for metastatic humeral fractures were included in this study. Data on patient demographics, new Katagiri score, operative time, amount of blood loss, bone union rate, range of motion (ROM) of the shoulder and elbow, and perioperative complications were obtained.ResultsTwelve patients (seven men and five women) with 14 fractures were included in this study. The median operative time was 92.6 ± 28.9 min (range, 57–175 min) and the median amount of intraoperative blood loss was 106.1 ± 109.5 g (range, 10–330 g). No patient required surgery-related transfusion. The median duration of acquisition of active elbow ROM of>100° and active shoulder flexion of >90° were 8.9 ± 6.6 days (range, 1–30 days) and 17.5 ± 13.0 days (range, 6–47 days), respectively. The mean follow-up period was 10.0 ± 9.0 months (range, 1–33 months). There were no complications, and no patient required any further surgery for the affected humerus until death.ConclusionMIPO using an LP provided acceptable functional outcomes in advanced-stage cancer patients with metastatic humeral fractures during their limited lifetime.     

Dual Locking Plate Osteosynthesis for 3- or 4-Part Proximal Humeral Fractures Combined with Multiple Fractures of the Greater Tuberosity

BackgroundThis retrospective study was conducted to evaluate the efficacy of dual locking plate osteosynthesis for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.MethodsFrom January 2012 to December 2018, 19 skeletally mature patients, who suffered 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity, were treated with open reduction and internal fixation using a dual locking plate technique through a delto-pectoral approach. Indexes for evaluation included fracture healing, quality of reduction, and incidence of complications (infections, screw perforation into the glenohumeral joint, subacromial impingement, hardware failure, avascular necrosis, and loss of reduction). Shoulder function was evaluated using Constant–Murley scoring.ResultsThe patients were assessed at a mean time of 25.3 months after surgery. Union of fractures was radiographically confirmed for all 19 patients. The mean Constant–Murley patient score was 85.2 points, and complications were identified in two patients during follow-up evaluations.ConclusionsThe method of using dual locking plate osteosynthesis through a delto-pectoral approach resulted in a satisfactory union rate, excellent fracture reduction, low complication rate and good shoulder function for patients with complex proximal humeral fractures. The method is effective for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.     

复杂肱骨近端骨折人工肱骨头置换术中肩袖重建的长期疗效观察

目的探讨Neer 3、4部分肱骨近端骨折人工肱骨头置换术中肩袖重建的远期临床效果。方法回顾性分析自2001-01—2012-12采用人工肱骨头置换术治疗的25例Neer 3、4部分肱骨近端骨折。术前测量健侧大结节最低点至肱骨头最高点的距离,术中尽量解剖复位肱骨大、小结节,合理控制假体高度及后倾角度,尽可能修复重建损伤肩袖,术后分阶段康复锻炼。结果本组22例获得有效随访,随访时间平均120(49~190)个月。末次随访时ASES评分为80~92(86.28±3.36)分,肩关节内旋至T10水平,患肢主动前屈上举125°~135°,外旋36°~42°。1例合并臂丛神经损伤者术后肩关节功能恢复满意。结论对于骨折端无法良好复位、肱骨头缺血性坏死可能性大的复杂肱骨近端骨折,人工肱骨头置换同时进行精细的肩袖重建可以获得无痛和良好运动范围的肩关节。     

Short-term Clinical Outcome of Dual Plate Fixation in the Treatment of Proximal Humerus Fractures with Calcar Comminution

Objective

Calcar comminution has been considered to be the main cause of the failure of internal fixation and fracture nonunion in proximal humerus surgery. Anatomical reduction and increasing the strength of internal fixation is the key to success. The purpose of this study was to investigate the short-term clinical effect of dual plate fixation in the treatment of proximal humeral fractures with calcar comminution.

Methods

The data of 37 patients with proximal humeral fractures with calcar comminution, treated in our departments from July 2018 to April 2020, were retrospectively analyzed. These patients were treated with anterior plate and lateral PHILOS plate, and followed up for more than 12 months, including 25 cases in Tianjin Hospital and 12 cases in Shanghai General Hospital. The patients included 12 males and 25 females, their age was 54.89 ± 13.59 years (range from 32–79 years), and 21 patients had dominant hand injury. According to the Neer classification, there were 11 two-part fractures, 22 three-part fractures, and four four-part fractures. The range of motion of the shoulder joint, visual analog scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant–Murley shoulder score, neck-shaft angle, anterior–posterior angle, and other complication scores were recorded at the last follow-up.

Results

All 37 patients were followed up after operation, and the follow-up time was 21.81 ± 7.35 months (range from 12–36 months). The fractures of all 37 patients had healed at the last follow-up visit. The neck-shaft angle measured immediately after operation was 132.59° ± 8.34°, and the neck-shaft angle measured at the last follow-up visit was 132.38 ± 8.53°. The anterior–posterior angle measured immediately after surgery was 3.45° ± 0.81°, and the anterior–posterior angle at the last follow-up visit was 3.66° ± 0.77°. The range of motion of the shoulder joint was as follows: the shoulder joint could be forward elevated by 158.11° ± 13.09° (range: 140°–180°), rotated externally by 38.38° ± 7.55° (range: 20°–45°), and internally rotated to T4-L4 level. The VAS score was 0.46 ± 0.87 (range: 0–3), the ASES was 86.58 ± 8.79 (range: 56.7–100), and the Constant–Murley score was 88.76 ± 8.25 (range: 60–100). Thirty-three cases were excellent, and four cases were good. No obvious complications occurred.

Conclusion

The combination of anterior plate and lateral PHILOS plate in the treatment of proximal humeral fractures with calcar comminution can achieve stable fixation, and the postoperative clinical and imaging outcome was satisfactory. Firstly, the anterior plate can provide temporary stability when the Kirschner wires are removed, which can provide space for lateral plate placement during fracture reduction and fixation. Secondly, additional support by the anterior plate can provide higher stability in complex fractures with calcar comminution.     

Radiographic and clinical results of tension suture fixation using two washers with PHILOS plate for proximal humeral fractures

IntroductionThe purpose of this study was to evaluate the radiographic and clinical results of tension suture fixation using two washers with PHILOS plate (Synthes, West Chester, PA, USA) for proximal humeral fractures.Patients and methodsConsecutive 39 patients were included and divided into two groups of adequate and inadequate medial support (MS (+) group vs MS (−) group). The mean follow-up period was 45months (range: 26–69 months). The mean age at the time of surgery was 59 years (range: 17–86 years) and there were 12 men and 27 women. The clinical results were evaluated using the visual analogue scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV). The radiographic results were evaluated by serial radiographs and Paavolainen method, which measures the neck-shaft angle (NSA). We used the Paired T and Kruskal-Wallis test to compare radiographic and clinical results between the two groups.ResultsBony union was achieved in 37 cases (94.9%). The mean NSA was changed from 133.5° postoperatively to 131.0° at the final follow-up period, but this change was not statistically significant. Thirty-five cases (89.8%) had good radiographic results as determined by the Paavolainen method. The mean final VAS pain score, ASES score, and SSV were 1.3, 87.3, and 86.0%, respectively. There were no significant differences between the two groups with respect to radiographic and clinical outcomes. Eight cases (20.5%) had complications including 5 with shoulder stiffness, 1 experiencing nonunion by fixation failure, 1 malunion, and 1 migration of greater tuberosity.ConclusionTension suture fixation using two washers with PHILOS plate for proximal humeral fractures yielded satisfactory radiographic and clinical results. It can be a treatment option that can reduce varus deformity and fixation loss.     

反置肩关节置换治疗肱骨近端骨折中影响术后肱骨大结节愈合的因素分析

目的分析探讨肱骨近端骨折反置肩关节置换术治疗中可能影响术后肱骨大结节愈合时间的影响因素。方法回顾分析2018年8月至2019年8月上海交通大学医学院附属瑞金医院骨科收治的14例患者;其中男4例,女10例,年龄67~95(80.0±8.1)岁;左侧8例,右侧6例。所有患者均因肱骨近端骨折行反置肩关节置换术。通过术前及术后影像学测量分析可能的影响因素。结果肱骨近端骨折反置肩关节置换治疗中,影响肱骨大结节骨折愈合时间的主要因素为大结节与近端皮质是否接触(P<0.01)、肱骨大结节骨块是否粉碎(P=0.01;P=0.04)以及肱骨大结节骨块前后向长度(P=0.02)。相比之下,肱骨近端骨折骨折是否合并不可修复肩袖损伤对反置肩关节置换术后肱骨大结节愈合时间无明显影响。结论采用反置肩关节置换治疗肱骨近端骨折,肱骨大结节与近端皮质不连续会导致肱骨大结节术后延迟愈合。粉碎的肱骨大结节尤其是前后向骨块较小的肱骨大结节可延长术后大结节愈合所需时间。     

Should the supraspinatus tendon be excised in the case of reverse shoulder arthroplasty for fracture?

European Journal of Orthopaedic Surgery & Traumatology - In the case of reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHFs) with tuberosity reconstruction, it is unclear...     

Reverse shoulder arthroplasty for proximal humeral fractures: better clinical midterm outcome after primary reverse arthroplasty versus secondary reverse arthroplasty after failed ORIF in the elderly

BackgroundJoint replacement surgery as a treatment for complex proximal humeral fractures is an established option, especially in the elderly. In light of the increased attention to reverse total shoulder arthroplasty (rTSA), this study has analyzed the outcomes of patients with primary reverse arthroplasty and after secondary reverse arthroplasty for failed osteosynthesis.MethodsWe retrospectively reviewed 57 patients with an average age of 76 years (min. 55; max. 94; SD 7) from 2010 and 2015 who underwent primary rTSA (30) and secondary rTSA after the failure of plate osteosynthesis (27) after proximal humeral fractures. The functional outcome of the operated shoulder was evaluated by clinical scores (Constant-Score, ASES, DASH and Oxford), range of motion (RoM), pain and activity level.ResultsPrimary rTSA had a significantly better functional outcome, mean-follow-up 37.3 months, measured by Constant-Score (57.13 vs 45.78 points; p= .015) compared to secondary RTSA, mean follow-up 42.1 months. A significantly better active abduction (P= .002), forward flexion (P = .003) and internal rotation (P = .037) was observed in the primary rTSA group, especially in the follow-up > 35 months.ConclusionReverse shoulder arthroplasty is an effective treatment for proximal humeral fractures as primary or revision surgery. The reliable clinical outcome especially in the follow-up to 40 months after primary reverse arthroplasty may suggest to prefer rTSA for complex humeral fractures in the elderly.Level of evidenceLevel III; Retrospective comparative study