Date Published: January 9, 2013
Publisher: Hindawi Publishing Corporation
Author(s): A. Panagopoulos, P. Tsoumpos, K. Evangelou, Christos Georgiou, I. Triantafillopoulos.
Background. The purpose of this study was to report our experience with shoulder hemiarthroplasty in the context of old trauma.
Methods. 33 patients with failed treatment for a complex proximal humeral fracture underwent prosthetic hemiarthroplasty. There were 15 men and 18 women with a mean age of 58.1 years. The average period from initial treatment was 14.9 months. Sequelae included 11 malunions, 4 nonunions, 15 cases with avascular necrosis (AVN) and 3 neglected posterior locked dislocations. Follow up investigation included radiological assessment and clinical evaluation using the Constant score and a visual analogue pain scale.
Results. After a mean follow up of 82.5 months the median Constant score was 75.7 points, improved by 60% in comparison to preoperative values. Greater tuberosity displacement, large cuff tears and severe malunion were the factors most affected outcome. No cases of stem loosening or severe migration were noted. 60% of the patients were able to do activities up to shoulder level compared with 24% before reconstruction.
Conclusions. Late shoulder hemiarthroplasty is technically difficult and the results are inferior to those reported for acute humeral head replacement, nonetheless remains a satisfactory reconstructive option when primary treatment fails.
Shoulder hemiarthroplasty is a technically challenging procedure which can predictably restore shoulder-level function in patients with 4-part fractures, some 3-part fractures, fracture dislocations, head-splitting fractures, and impaction fractures of the humeral head with involvement of more than 50% of the articular surface [1–4]. Early surgical intervention within 2 weeks postinjury, accurate tuberosity reconstruction, and appropriate height and retroversion of the prosthesis are the factors with the greatest impact on functional outcome [5–8].
Between 2004 and 2007, thirty-eight patients underwent shoulder hemiarthroplasty after failed conservative or operative treatment for complex proximal humeral fractures in our department. Three patients were lost from followup, and two died from reasons unrelated to the fracture leaving a cohort of 33 patients, with a minimum followup of 5 years, for the outcome analysis. There were 18 women and 15 men with a mean age of 58.1 years old (range, 34 to 83 years old) at implantation. The dominant arm was involved in 23 (69.7%) cases. Seven patients performed heavy or manual labor, fifteen were sedentary, and eleven were retired.
Our surgical technique was similar to that original described by Neer [5, 17]. As there were not any preoperative indications or intraoperative findings of severe glenoid degeneration, all patients were managed with shoulder hemiarthroplasty without glenoid replacement. Two types of prosthetic implants were used (Neer II and Biomet). The deltopectoral approach was used in all cases. In 9 cases, diffuse adhesive capsulitis was noted requiring extended capsular release for achieving a functional range of motion. Full-thickness rotator cuff tears were noted in 4 cases (2 of supraspinatus tendon and two of both supraspinatus and infraspinatus tendons), whereas partial-thickness tears was detected in 7 cases; all tears were repaired with non-absorbable Ethibond-2 sutures. The biceps tendon was normal in 20 cases, frayed or degenerative in 11, and complete ruptured in 2 cases. Biceps tenodesis was performed in 8 cases. Greater tuberosity osteotomy was performed in 7 cases and double osteotomy of both tuberosities in 3 cases. Two to three pairs of heavy nonabsorbable sutures (Ethibond no.5) were applied to each tuberosity near the insertion of the adjacent tendon prior to removal of the humeral head. The later was carefully showed off in its anatomical neck, and the humeral canal was prepared without aggressive reaming. Two 2.7 mm drill-holes were created in each side of the diaphysis both laterally and medially, and two pair of sutures were placed for tuberosity fixation. Humeral component was placed after cementing the canal at the appropriate height, with 30°–35° of retroversion. Tuberosity fixation was performed thereafter with the horizontal intertuberosity sutures incorporated to the lateral fins of the prosthesis and the vertical diaphyseal tuberosity sutures in a cruciate tension band fashion that ensures stable fixation of the construct and adequate balance of the adjacent rotator cuff tendons. Additional cancellous bone grafting was placed into the proximal humeral space in 6 cases for filling the spaces between the implant and the tuberosities. Finally, the rotator cuff interval was closed with separate sutures and the deltopectoral space with absorbable sutures in a figure of eight manner. The arm was rested in internal rotation in a simple sling with the elbow at the side for 4–6 weeks or was immobilized in abduction in a special brace if a full-thickness rotator cuff or tuberosity osteotomy had been performed.
The mean followup period was 82.5 months (range, 61 to 96 months). The median Constant score was 75.7 points, improved by 60% in comparison to preoperative values (mean, 47.9 points). In the pain analogue scale, there was an averaged improvement from 4 to 8 points. According to our criteria, the result was excellent in nine patients, very good in eleven, moderate in ten and unsatisfactory in four. Active forward elevation increased from 56 degrees to 100 degrees, active external rotation increased from 12 degrees to 35 degrees, and finally, active internal rotation increased from the ability of the thumb to reach the sacrum (range, greater trochanter to the first lumbar vertebral body) to the second lumbar vertebral body (range, trochanter to T7). Sixty per cent of the patients were able to do activities up to shoulder level compared with 24% before arthroplasty (Figure 2). Overall, 79% of the patients were satisfied with the final outcome and said that they would repeat the operation in similar circumstances (Figures 2, 3, and 4).
Complications after proximal humeral fracture fixation are some of the most difficult situations to manage in shoulder reconstruction. An anticipated and reliable functional result is difficult to obtain because of the complexity of bone pathology and the impaired soft tissue envelope, especially if the patient had already undergone surgery. The surgeon has to deal with malunion, nonunion or AVN of the proximal humerus, displacement of the tuberosities, rotator cuff tears, and associated soft-tissue contractures. In the presence of sever osteoporosis, significant bone loss, articular incongruity, and glenoid erosion, the only indication is prosthetic replacement of the proximal humerus. Generally, a satisfactory result may be expected in 20% to 75% of the cases, with pain relief obtained in more than 85% [6, 18, 19]. Kontakis et al.  in a systematic review of 810 early hemiarthroplasties in 808 patients for proximal humeral fractures not only concluded that most patients had no pain or only mild pain but also that the level of function before injury was almost never regained. In the present study of late hemiarthroplasties for proximal humeral fractures, 29/33 patients had a good or acceptable, even moderate outcome, whereas improvement of pain was up to 80%.
Shoulder hemiarthroplasty for management of posttraumatic complications of fracture of the proximal humerus is a technically demanding procedure with unpredictable results. The high rate of complications is often related to technical difficulties, a scarred deltoid, adhesions of rotator cuff tendons, and malunion of the tuberosities. Careful selection of the patients, detail preoperative planning, and meticulous surgical technique are essential elements for a successful outcome. The postoperative rehabilitation program should be modified based on the surgical findings and the technique used. In this manner, certain possible secondary complications could be avoided, and the long-term results will be more favorable.