SHOULDER AND ELBOW
Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus OUTCOMES AND COMPLICATIONS M. M. Hussey, S. E. Hussey, M. A. Mighell From Florida Orthopaedic Institute, Florida, United States
Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72.
M. M. Hussey, MD, Orthopaedic Surgeon Arkansas Specialty Orthopaedics, 600 S McKinley, Little Rock, Arkansas, 72205, USA. S. E. Hussey, PhD, Postdoctoral Fellow The University of South Florida, 4202 E Fowler Ave, Tampa, Florida 33620, USA. M. A. Mighell, MD, Orthopaedic Surgeon Florida Orthopaedic Institute, 13020 Telecom Dr, Tampa, Florida 33637, USA. Correspondence should be sent to Dr M. M. Hussey; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B7. 35713 $2.00 Bone Joint J 2015;97-B:967–72. Received 5 January 2015; Accepted after revision 5 March 2015
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Most fractures of the proximal humerus are minimally displaced and amenable to nonoperative treatment, with the majority of patients achieving a satisfactory result once the fracture unites.1-5 However, operative intervention may be necessary to restore alignment and improve the chances of a successful outcome when there is significant displacement or comminution.6,7 Many methods of fixation have been advocated, including closed reduction and percutaneous pinning,8-10 open reduction and internal fixation (ORIF),7,11,12 intramedullary nail (IMN) fixation,13-15 non-constrained arthroplasty,16-18 and more recently, reverse shoulder arthroplasty (RSA).19-21 Although successful outcomes have been reported using internal fixation to treat these complex injuries,7,11,12 there is a high rate of post-operative complications. Most of these relate to avascular necrosis of the humeral head, iatrogenic screw perforation, malunion or nonunion, displacement of the tuberosities and deep infection.22-25 Poor surgical technique, comminution of the fracture, and osteoporosis are frequently cited as reasons for loss
of fixation and the development of complications, leading to loss of function and increase in pain.11,24 The rate of further surgery owing to failure of internal fixation has ranged from 13% to 34%, even when newer locking plate technology is used.7,11,26-28 Few options are available to the surgeon when fixation fails; these include removal of the hardware, revision of fixation, capsular release and subacromial debridement, and conversion to arthroplasty.23,25,27 Owing to the dysfunction of the rotator cuff and displacement of the tuberosities that often accompanies failed internal fixation, RSA has shown promise as a form of treatment.29 The biomechanical properties of RSA, with its semiconstrained design and reduced reliance on union of the tuberosities and rotator cuff function, give it a theoretical advantage over a traditional nonconstrained arthroplasty. A more reliable improvement of outcomes and pain relief might be anticipated in these complicated cases. This is the first study, to our knowledge, that has specifically evaluated the outcomes of RSA for the treatment of failed internal fixation of a 967
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Fig. 1a
Fig. 1b
Radiographs showing types of failed internal fixation in a) a patient treated with open reduction and internal fixation showing avascular necrosis and post-traumatic arthritis (superior migration of the remaining humeral head is also seen) and b) a patient treated with intramedullary nail fixation showing complete collapse of the humeral head and perforating proximal screws.
Table I. Patient demographics Variable
No. or mean (range)
Patients (total) Male Female Age at IF (yrs) Age at RSA (yrs) Time from IF to RSA (mths) Surgical side Right Left Follow-up from RSA (mths) Diagnosis for revision Avascular necrosis/PTA Painful hardware/PTA Nonunion Malunion Rotator cuff deficiency
19 4 15 63 (44 to 76) 66 (52 to 82) 28 (1 to 130) 13 6 36 (25 to 60) 5 4 6 2 2
IF, internal fixation; RSA, reverse shoulder arthroplasty; PTA, post-traumatic arthritis
fracture of the proximal humerus. We hypothesised that RSA, as a salvage procedure under these circumstances, would lead to improved function and decreased pain.
Patients and Methods Between February 2007 and August 2012, a total of 19 patients with persistent symptoms after undergoing internal fixation of a fracture of the proximal humerus, were treated with removal of the hardware and RSA at a single institution. The inclusion criteria consisted of patients initially treated with either ORIF or fixation using an IMN, who were managed with a single-stage revision to a RSA, and had a minimum of two years clinical and radiological
follow-up. Those who had previously undergone revision surgery, or had deep infection, were excluded. There were 15 women and four men; their mean age was 63 years (44 to 76) at the time of initial fixation. The mean time between initial fixation and RSA was 28 months (1 to 130) and the mean follow-up after RSA was 36 months (25 to 60). A proximal humeral plate and screws was removed in 16 patients (Fig. 1a), with an IMN and screws removed in three (Fig. 1b). The demographic details are shown in Table I. All operations were undertaken by a fellowship-trained surgeon (MAM) with the patient in the beach-chair position using the deltopectoral approach. Fluoroscopy was THE BONE & JOINT JOURNAL
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Table II. Clinical Results presented as means (range) Clinical results* VAS pain (points) ASES (points) SST (points) Range of movement (º) Forward flexion Abduction External rotation Internal rotation (level)
Pre-operative 6.8 (5.0 to 10.0) 27.8 (7.0 to 63.0) 0.7 (0.0 to -1.0)
Post-operative 4.3 (2.0 to 7.0) 50.1 (25.0 to 83.3) 3.2 (0.0 to 10.0)
Improvement 2.6 (0.0 to 10.0) 22.3 (0.0 to 76.0) 2.3 (0.0 to 7.0)
p-value 0.012 0.019 0.020
58.7 (0.0 to 110.0) 58.7 (0.0 to 110.0) 10.7 (-10.0 to 45.0) 1.5 (0.0 to 2.0)
101.1 (10.0 to 170.0) 89.1 (20.0 to 180.0) 23.1 (-20.0 to 50.0) 2.6 (0.0 to 8.0)
42.4 (0.0 to 120.0) 30.4 (0.0 to 140.0) 12.4 (0.0 to 70.0) 1.1 (0.0 to 6.0)
< 0.001 0.012 0.043 0.034
* Pre- and post-operative pain and function scores were evaluated using the Wilcoxon signed-rank test and a paired Student’s t-test was used to evaluate pre- and post-operative range of movement values VAS, visual analogue scale; ASES, American Shoulder and Elbow Surgeons; SST, simple shoulder test
used to aid removal of the hardware and preparation of the humeral canal. The subscapularis was released to gain access to the glenohumeral joint. However, when there was nonunion of the lesser tuberosity, it was mobilised to allow exposure of the proximal humerus. After dislocation and removal of previously placed implants, the residual humeral head was resected in approximately 30° of retroversion. If the greater tuberosity was not united, it was mobilised for suturing to the prosthesis at a later stage. A circumferential capsular release and labral excision were performed in order to maximise exposure of the glenoid. A RSA was used instead of a nonconstrained arthroplasty because of the scarring and fibrosis of the rotator cuff that was present after the previous surgery. The Reverse Shoulder Prosthesis (DJO Surgical, Austin, Texas), which has a glenosphere with a lateralised centre-of-rotation, was used. A baseplate and appropriately sized glenosphere were placed onto the prepared glenoid and the humeral component was introduced in 30° retroversion. When present, the tuberosities were repaired around the humeral component. Passive pendulum exercises were started on the first post-operative day under the care of a physiotherapist. A shoulder immobiliser was worn at all times for six weeks, at which time passive and active-assisted exercises were started, with full active exercises commenced 12 weeks post-operatively. Clinical outcome was assessed prospectively using the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST) and a 0 to 10 (best to worst) visual analogue scale (VAS) for pain. The patients also rated their satisfaction with the procedure (excellent, good, satisfactory, or unsatisfactory). The range of movement (ROM) including forward flexion, abduction, internal and external rotation was recorded pre-operatively, and at the three, six and 12-month postoperative visits, and annually thereafter. Internal rotation was recorded as the highest vertebral level reached by the thumb. The most recent outcome scores and ROM were compared with the pre-operative values. The medical records and radiographs were assessed for survivorship and revision. The causes of failure and/or revision were recorded in the following categories: infection, VOL. 97-B, No. 7, JULY 2015
failure/loosening (glenoid or humeral), periprosthetic fracture, or instability. Complications relating to the surgery were recorded. Radiographic analysis. Pre- and post-operative radiographs included a true anteroposterior (AP) view, AP views in internal and external rotation, axillary lateral, and scapular-Y views. The pre-operative radiographs were assessed (MMH) for causes of failure to include: avascular necrosis (AVN), post-traumatic arthritis (PTA), iatrogenic screw perforation, malunion, nonunion, displacement of the tuberosities and implant failure. The most recent radiographs were evaluated for failure of the baseplate, dissociation of the components, stress fracture of the acromion, instability, humeral loosening, periprosthetic fracture, and scapular notching. Failure of the baseplate was defined as breakage of a screw or migration of the component. Dissociation was specified as either that of the glenosphere or humeral component. Humeral loosening was assessed using the method described by Sperling et al.30 Humeral periprosthetic fractures were classified as described by Wright and Cofield.31 Scapular notching was assessed according to method of Sirveaux et al.32 Statistical analysis. Pre- and post-operative pain and function scores were evaluated using the Wilcoxon signed-rank test. A paired Student’s t-test was used to evaluate pre- and post-operative ROM values. Differences were considered significant at a p-value < 0.05.
Results The outcome scores and ROM are summarised in Table II. There were significant improvements in all scores, in pain and in ROM in all planes. Radiological analysis at final follow-up showed Grade I inferior scapular notching around the baseplate in two patients (11%). A periprosthetic fracture of the humerus occurred in three patients (16%), and aseptic loosening of the humeral component occurred in two (11%). One of the patients with a periprosthetic fracture had associated humeral loosening. There was no evidence of failure of the baseplate, dissociation of the components, instability, or acromial stress fracture.
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Table III. Complications Pre-operative fixation
Complication
Treatment
Patient 1 Patient 2
ORIF ORIF
Patient 3 Patient 4
IMN IMN
Patient 5
ORIF
Humeral loosening Humeral loosening/bone loss with pathological periprosthetic humeral fracture Periprosthetic humeral fracture Periprosthetic fracture (#1) Radial nerve palsy Periprosthetic fracture (#2) Intra-operative humeral fracture
Revision humeral component Implant removal/hemiarthroplasty tumour prosthesis Non-operative (declined follow-up) Revision humeral component /allograft Nerve exploration found intact ORIF Cortical allograft/cerclage
ORIF, open reduction internal fixation; IMN, intramedullary nail fixation
A total of eight major complications were recorded in five patients (26%) (Table III). Three patients (16%) required at least one revision procedure. One patient treated for nonunion after ORIF had gross loosening of the humeral component with resorption of the tuberosities two years post-operatively. She underwent onestage revision using a long stemmed humeral component and allografting. She rated the outcome as satisfactory 24 months post-operatively. Gross humeral loosening with an associated pathological fracture (oblique Type B) was also seen in a second patient two years after RSA. She underwent revision using a hemiarthroplasty tumour prosthesis owing to extensive humeral bone loss and rated her outcome as satisfactory 33 months post-operatively. Periprosthetic fractures occurred around a well-fixed humeral component in two patients, both of whom had been previously managed with an IMN. A completely displaced fracture (transverse Type A) was sustained three years post-operatively in one patient because of a fall. He declined further surgery. The second patient sustained a mildly displaced periprosthetic fracture (oblique Type B) five years post-operatively also due to a fall (Fig. 2). Revision was undertaken using a cemented long stemmed humeral component with cortical allograft and cerclage wire. This operation was complicated by a radial nerve palsy, and she subsequently fell again two months post-operatively sustaining another periprosthetic fracture (oblique Type B) at the supracondylar level. This was treated with dual-column ORIF, at which time the radial nerve was explored and found to be intact. The fracture was found united ten weeks after this procedure with subsequent resolution of the radial nerve palsy six months later. An intra-operative fracture occurred in one patient who had been treated previously with fixation using a plate and screws. After removal of the hardware, dislocation of the joint was performed and an iatrogenic fracture occurred through an empty screw hole in the shaft of the humerus while externally rotating the humerus. Supplementary cortical allograft and cerclage fixation was undertaken around a long stemmed humeral component. She rated the outcome as unsatisfactory 25 months after this procedure. A total of 11 patients rated their outcome as excellent (57.9%), four as good (21.1%), one as satisfactory (5.3%), and three as unsatisfactory (15.8%).
Discussion RSA is an appealing surgical option when managing patients with failed internal fixation, as its design is inherently less dependent on the integrity of the rotator cuff, and it allows the replacement of damaged articular surfaces. Using this form of treatment, our short-term results indicate that modest improvements can be reliably achieved in most patients. The patients had a mean improvement in ASES score of > 20 points, with significant improvement in ROM and reduction in pain. Measurements of forward elevation and abduction indicated that most patients could now elevate the arm to a level at or above the shoulder, with mean gains of 42° and 30°, respectively. Improvements in rotation were also seen, with mean gains of external rotation of > 10°, and increased mean internal rotation by two vertebral levels. Although no specific studies have addressed the use of RSA for treatment of failed internal fixation, studies relating to other sequelae of fractures can be extrapolated to this problem. Recently, Raiss et al29 examined the results of RSA for a heterogenous group of 32 patients with nonunion of a proximal humeral fracture previously treated either conservatively or surgically. Results showed a significant improvement in clinical outcome scores, as well as ROM, with mean forward flexion improving from 43° preoperatively to 110° post-operatively. There was no incidence of component loosening or periprosthetic fracture. However, they reported a rate of scapular notching of 50% and a rate of dislocation of 34%. Our study had an 11% notching rate and experienced no dislocations. However, we had a humeral loosening and periprosthetic fracture rate of 11% and 16%, respectively. A further operation was required in 28% of their cohort due to a complication. Significantly more complications and dislocations were seen in those patients whose tuberosities were resected at the time of RSA, with the authors recommending preservation of the tuberosities. Levy et al33 reported the use of a RSA in the treatment of failed hemiarthroplasty for a proximal humeral fracture in 29 patients. They noted significant improvements in the mean ASES and SST scores of 29.8 and 1.7 points, respectively. The mean forward elevation and abduction also improved (34.6° and 36.3°, respectively). However, mean external rotation (6.4°) failed to show significant improvement. Our findings THE BONE & JOINT JOURNAL
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Fig. 2a
Fig. 2b
Fig. 2d
Fig. 2e
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Fig. 2c
Fig. 2f
Radiographs showing periprosthetic fracture in 52-year-old female patient a) with failed intramedullary nail fixation, b) immediate post-operative anteroposterior radiograph after revision with reverse shoulder arthroplasty, c) five years after revision; she sustained an oblique Type B periprosthetic fracture after a fall. There is heterotopic ossification around the proximal humerus. d) An immediate post-operative radiograph after revision using a long stemmed humeral component supplemented with cortical allografting. e) Two months later, she fell again sustaining a second periprosthetic fracture at the level of the distal humerus. The humeral component was found to be stable. f) Anteroposterior radiograph showing dual-column ORIF of the second fracture.
were similar, with the notable exception of significantly improved rotation. Of note, however, is that eight shoulders required the use of a proximal humeral allograft due to extensive proximal bone loss, which probably influenced the improvements seen in rotation. Similar to our study, they reported a rate of complications of 28%. Willis et al34 reviewed 16 patients who underwent a RSA for management of malnunion of proximal humeral fractures which had been initially treated conservatively. The greater tuberosity was not osteotomised in any patient, even in those with severe malunion of a tuberosity, preferring to accept its malaligned position. Overall, all patients rated their final outcome as satisfactory or better, at shortterm follow-up. The mean ASES and SST scores improved VOL. 97-B, No. 7, JULY 2015
significantly (35 and three points, respectively), as did all mean ROM (forward elevation 52°, abduction 57°, external rotation 25° and internal rotation three vertebral levels). These results show slightly greater improvements in all functional measures than in our study. The inferior results seen in our patients probably relate to the difficulties in performing revision surgery with removal of implants. A relatively high rate of major complications occurred, requiring further surgery in three (16%) of our patients. Two periprosthetic fractures occurred in patients who had previously been treated with an IMN. We speculate that the empty holes from the distal interlocking screws created a stress riser from which a fracture propagated. One intra-operative fracture occurred while surgically dislocating the glenohumeral
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joint, with the fracture propagating through an empty shaft screw hole. We now dislocate the glenohumeral joint prior to removal of implants to reduce the risk of iatrogenic fracture. No patients had a dislocation and the rate of scapular notching (11%) was low. The RSA used in this study has a lateralised centre-of-rotation, which previous studies have shown to have a low rate of notching.33,34 Limitations of this study include its retrospective nature, the relatively small sample size and lack of long-term followup. The strengths include the fact that it was performed at a single institution by a high-volume fellowship trained shoulder surgeon. This served to decrease variability in surgical technique and improve clinical outcomes. Moreover, a single RSA was used. Our rationale for using a RSA stems from the technical difficulties in being able to balance the glenohumeral joint with a traditional nonconstrained prosthesis reliably, due to extensive fibrosis of the rotator cuff and frequent malunion or nonunion of the tuberosities. Previous authors have shown unpredictable results using a nonconstrained prosthesis.35,36 Many factors should be considered before proceeding with a RSA for failed internal fixation. Specifically, younger patients should be considered candidates for hardware removal, revision ORIF, or even hemiarthroplasty before performing a RSA, given the concerns regarding the longterm survival of a RSA. In certain patients however, we have found RSA to give reasonable and reliable results when managing this difficult problem. Author contributions: M. M. Hussey: Study design, Data collection, Data analysis, Writing the paper. S. E. Hussey: Data analysis, Editing the paper. M. A. Mighell: Study design, Performing surgeries, Writing the paper. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by J. Scott and first proof edited by G. Scott.
References 1. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001;72:365–371. 2. Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand 2003;74:580–585. 3. Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg 2009;18:612–621. 4. Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury 1998;29:349–352. 5. Clement ND, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of proximal humeral fractures in the elderly: predictors of mortality and function. Bone Joint J 2014;96-B:970–977. 6. Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg [Br] 2004;86-B:848–855. 7. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011;20:747–755. 8. Chen CY, Chao EK, Tu YK, Ueng SW, Shih CH. Closed management and percutaneous fixation of unstable proximal humerus fractures. J Trauma 1998;45:1039–1045. 9. Herscovici D Jr, Saunders DT, Johnson MP, Sanders R, DiPasquale T. Percutaneous fixation of proximal humeral fractures. Clin Orthop Relat Res 2000;375:97– 104. 10. Keener JD, Parsons BO, Flatow EL, et al. Outcomes after percutaneous reduction and fixation of proximal humeral fractures. J Shoulder Elbow Surg 2007;16:330–338.
11. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg [Am] 2009;91A:1320–1328. 12. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg [Am] 2002;84-A:1919–1925. 13. Adedapo AO, Ikpeme JO. The results of internal fixation of three- and four-part proximal humeral fractures with the Polarus nail. Injury 2001;32:115–121. 14. Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg 2004;13:191–195. 15. Kazakos K, Lyras DN, Galanis V, et al. Internal fixation of proximal humerus fractures using the Polarus intramedullary nail. Arch Orthop Trauma Surg 2007;127:503– 508. 16. Mighell MA, Kolm GP, Collinge CA, Frankle MA. Outcomes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg 2003;12:569–577. 17. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011;20:1025–1033. 18. Prakash U, McGurty DW, Dent JA. Hemiarthroplasty for severe fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11:428–430. 19. Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg 2013;22:32–37. 20. Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg [Am] 2013;95-A:2050–2055. 21. Garrigues GE, Johnston PS, Pepe MD, et al. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics 2012;35:703–708. 22. Agudelo J, Schürmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 2007;21:676– 681. 23. Brunner A, Jöckel JA, Babst R. The PFNA proximal femur nail in treatment of unstable proximal femur fractures--3 cases of postoperative perforation of the helical blade into the hip joint. J Orthop Trauma 2008;22:731–736. 24. Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 2010;19:489–494. 25. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg 2013;22:542–549. 26. Brunner F, Sommer C, Bahrs C, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma 2009;23:163–172. 27. Konrad G, Audigé L, Lambert S, Hertel R, Südkamp NP. Similar outcomes for nail versus plate fixation of three-part proximal humeral fractures. Clin Orthop Relat Res 2012;470:602–609. 28. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg [Am] 2008;90-A:233–240. 29. Raiss P, Edwards TB, da Silva MR, et al. Reverse shoulder arthroplasty for the treatment of nonunions of the surgical neck of the proximal part of the humerus (type3 fracture sequelae). J Bone Joint Surg [Am] 2014;96-A:2070–2076. 30. Sperling JW, Cofield RH, O'Driscoll SW, Torchia ME, Rowland CM. Radiographic assessment of ingrowth total shoulder arthroplasty. J Shoulder Elbow Surg 2000;9:507–513. 31. Wright TW, Cofield RH. Humeral fractures after shoulder arthroplasty. J Bone Joint Surg [Am] 1995;77-A:1340–1346. 32. Sirveaux F, Favard L, Oudet D, et al. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg [Br] 2004;86B:388–395. 33. Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg [Am] 2007;89-A:292–300. 34. Willis M, Min W, Brooks JP, et al. Proximal humeral malunion treated with reverse shoulder arthroplasty. J Shoulder Elbow Surg 2012;21:507–513. 35. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg 1995;4:271–280. 36. Boileau P, Trojani C, Walch G, et al. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 2001;10:299– 308. THE BONE & JOINT JOURNAL
Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus OUTCOMES AND COMPLICATIONS M. M. Hussey, S. E. Hussey, M. A. Mighell From Florida Orthopaedic Institute, Florida, United States
Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72.
M. M. Hussey, MD, Orthopaedic Surgeon Arkansas Specialty Orthopaedics, 600 S McKinley, Little Rock, Arkansas, 72205, USA. S. E. Hussey, PhD, Postdoctoral Fellow The University of South Florida, 4202 E Fowler Ave, Tampa, Florida 33620, USA. M. A. Mighell, MD, Orthopaedic Surgeon Florida Orthopaedic Institute, 13020 Telecom Dr, Tampa, Florida 33637, USA. Correspondence should be sent to Dr M. M. Hussey; e-mail: [email protected] ©2015 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.97B7. 35713 $2.00 Bone Joint J 2015;97-B:967–72. Received 5 January 2015; Accepted after revision 5 March 2015
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Most fractures of the proximal humerus are minimally displaced and amenable to nonoperative treatment, with the majority of patients achieving a satisfactory result once the fracture unites.1-5 However, operative intervention may be necessary to restore alignment and improve the chances of a successful outcome when there is significant displacement or comminution.6,7 Many methods of fixation have been advocated, including closed reduction and percutaneous pinning,8-10 open reduction and internal fixation (ORIF),7,11,12 intramedullary nail (IMN) fixation,13-15 non-constrained arthroplasty,16-18 and more recently, reverse shoulder arthroplasty (RSA).19-21 Although successful outcomes have been reported using internal fixation to treat these complex injuries,7,11,12 there is a high rate of post-operative complications. Most of these relate to avascular necrosis of the humeral head, iatrogenic screw perforation, malunion or nonunion, displacement of the tuberosities and deep infection.22-25 Poor surgical technique, comminution of the fracture, and osteoporosis are frequently cited as reasons for loss
of fixation and the development of complications, leading to loss of function and increase in pain.11,24 The rate of further surgery owing to failure of internal fixation has ranged from 13% to 34%, even when newer locking plate technology is used.7,11,26-28 Few options are available to the surgeon when fixation fails; these include removal of the hardware, revision of fixation, capsular release and subacromial debridement, and conversion to arthroplasty.23,25,27 Owing to the dysfunction of the rotator cuff and displacement of the tuberosities that often accompanies failed internal fixation, RSA has shown promise as a form of treatment.29 The biomechanical properties of RSA, with its semiconstrained design and reduced reliance on union of the tuberosities and rotator cuff function, give it a theoretical advantage over a traditional nonconstrained arthroplasty. A more reliable improvement of outcomes and pain relief might be anticipated in these complicated cases. This is the first study, to our knowledge, that has specifically evaluated the outcomes of RSA for the treatment of failed internal fixation of a 967
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Fig. 1a
Fig. 1b
Radiographs showing types of failed internal fixation in a) a patient treated with open reduction and internal fixation showing avascular necrosis and post-traumatic arthritis (superior migration of the remaining humeral head is also seen) and b) a patient treated with intramedullary nail fixation showing complete collapse of the humeral head and perforating proximal screws.
Table I. Patient demographics Variable
No. or mean (range)
Patients (total) Male Female Age at IF (yrs) Age at RSA (yrs) Time from IF to RSA (mths) Surgical side Right Left Follow-up from RSA (mths) Diagnosis for revision Avascular necrosis/PTA Painful hardware/PTA Nonunion Malunion Rotator cuff deficiency
19 4 15 63 (44 to 76) 66 (52 to 82) 28 (1 to 130) 13 6 36 (25 to 60) 5 4 6 2 2
IF, internal fixation; RSA, reverse shoulder arthroplasty; PTA, post-traumatic arthritis
fracture of the proximal humerus. We hypothesised that RSA, as a salvage procedure under these circumstances, would lead to improved function and decreased pain.
Patients and Methods Between February 2007 and August 2012, a total of 19 patients with persistent symptoms after undergoing internal fixation of a fracture of the proximal humerus, were treated with removal of the hardware and RSA at a single institution. The inclusion criteria consisted of patients initially treated with either ORIF or fixation using an IMN, who were managed with a single-stage revision to a RSA, and had a minimum of two years clinical and radiological
follow-up. Those who had previously undergone revision surgery, or had deep infection, were excluded. There were 15 women and four men; their mean age was 63 years (44 to 76) at the time of initial fixation. The mean time between initial fixation and RSA was 28 months (1 to 130) and the mean follow-up after RSA was 36 months (25 to 60). A proximal humeral plate and screws was removed in 16 patients (Fig. 1a), with an IMN and screws removed in three (Fig. 1b). The demographic details are shown in Table I. All operations were undertaken by a fellowship-trained surgeon (MAM) with the patient in the beach-chair position using the deltopectoral approach. Fluoroscopy was THE BONE & JOINT JOURNAL
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Table II. Clinical Results presented as means (range) Clinical results* VAS pain (points) ASES (points) SST (points) Range of movement (º) Forward flexion Abduction External rotation Internal rotation (level)
Pre-operative 6.8 (5.0 to 10.0) 27.8 (7.0 to 63.0) 0.7 (0.0 to -1.0)
Post-operative 4.3 (2.0 to 7.0) 50.1 (25.0 to 83.3) 3.2 (0.0 to 10.0)
Improvement 2.6 (0.0 to 10.0) 22.3 (0.0 to 76.0) 2.3 (0.0 to 7.0)
p-value 0.012 0.019 0.020
58.7 (0.0 to 110.0) 58.7 (0.0 to 110.0) 10.7 (-10.0 to 45.0) 1.5 (0.0 to 2.0)
101.1 (10.0 to 170.0) 89.1 (20.0 to 180.0) 23.1 (-20.0 to 50.0) 2.6 (0.0 to 8.0)
42.4 (0.0 to 120.0) 30.4 (0.0 to 140.0) 12.4 (0.0 to 70.0) 1.1 (0.0 to 6.0)
< 0.001 0.012 0.043 0.034
* Pre- and post-operative pain and function scores were evaluated using the Wilcoxon signed-rank test and a paired Student’s t-test was used to evaluate pre- and post-operative range of movement values VAS, visual analogue scale; ASES, American Shoulder and Elbow Surgeons; SST, simple shoulder test
used to aid removal of the hardware and preparation of the humeral canal. The subscapularis was released to gain access to the glenohumeral joint. However, when there was nonunion of the lesser tuberosity, it was mobilised to allow exposure of the proximal humerus. After dislocation and removal of previously placed implants, the residual humeral head was resected in approximately 30° of retroversion. If the greater tuberosity was not united, it was mobilised for suturing to the prosthesis at a later stage. A circumferential capsular release and labral excision were performed in order to maximise exposure of the glenoid. A RSA was used instead of a nonconstrained arthroplasty because of the scarring and fibrosis of the rotator cuff that was present after the previous surgery. The Reverse Shoulder Prosthesis (DJO Surgical, Austin, Texas), which has a glenosphere with a lateralised centre-of-rotation, was used. A baseplate and appropriately sized glenosphere were placed onto the prepared glenoid and the humeral component was introduced in 30° retroversion. When present, the tuberosities were repaired around the humeral component. Passive pendulum exercises were started on the first post-operative day under the care of a physiotherapist. A shoulder immobiliser was worn at all times for six weeks, at which time passive and active-assisted exercises were started, with full active exercises commenced 12 weeks post-operatively. Clinical outcome was assessed prospectively using the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST) and a 0 to 10 (best to worst) visual analogue scale (VAS) for pain. The patients also rated their satisfaction with the procedure (excellent, good, satisfactory, or unsatisfactory). The range of movement (ROM) including forward flexion, abduction, internal and external rotation was recorded pre-operatively, and at the three, six and 12-month postoperative visits, and annually thereafter. Internal rotation was recorded as the highest vertebral level reached by the thumb. The most recent outcome scores and ROM were compared with the pre-operative values. The medical records and radiographs were assessed for survivorship and revision. The causes of failure and/or revision were recorded in the following categories: infection, VOL. 97-B, No. 7, JULY 2015
failure/loosening (glenoid or humeral), periprosthetic fracture, or instability. Complications relating to the surgery were recorded. Radiographic analysis. Pre- and post-operative radiographs included a true anteroposterior (AP) view, AP views in internal and external rotation, axillary lateral, and scapular-Y views. The pre-operative radiographs were assessed (MMH) for causes of failure to include: avascular necrosis (AVN), post-traumatic arthritis (PTA), iatrogenic screw perforation, malunion, nonunion, displacement of the tuberosities and implant failure. The most recent radiographs were evaluated for failure of the baseplate, dissociation of the components, stress fracture of the acromion, instability, humeral loosening, periprosthetic fracture, and scapular notching. Failure of the baseplate was defined as breakage of a screw or migration of the component. Dissociation was specified as either that of the glenosphere or humeral component. Humeral loosening was assessed using the method described by Sperling et al.30 Humeral periprosthetic fractures were classified as described by Wright and Cofield.31 Scapular notching was assessed according to method of Sirveaux et al.32 Statistical analysis. Pre- and post-operative pain and function scores were evaluated using the Wilcoxon signed-rank test. A paired Student’s t-test was used to evaluate pre- and post-operative ROM values. Differences were considered significant at a p-value < 0.05.
Results The outcome scores and ROM are summarised in Table II. There were significant improvements in all scores, in pain and in ROM in all planes. Radiological analysis at final follow-up showed Grade I inferior scapular notching around the baseplate in two patients (11%). A periprosthetic fracture of the humerus occurred in three patients (16%), and aseptic loosening of the humeral component occurred in two (11%). One of the patients with a periprosthetic fracture had associated humeral loosening. There was no evidence of failure of the baseplate, dissociation of the components, instability, or acromial stress fracture.
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Table III. Complications Pre-operative fixation
Complication
Treatment
Patient 1 Patient 2
ORIF ORIF
Patient 3 Patient 4
IMN IMN
Patient 5
ORIF
Humeral loosening Humeral loosening/bone loss with pathological periprosthetic humeral fracture Periprosthetic humeral fracture Periprosthetic fracture (#1) Radial nerve palsy Periprosthetic fracture (#2) Intra-operative humeral fracture
Revision humeral component Implant removal/hemiarthroplasty tumour prosthesis Non-operative (declined follow-up) Revision humeral component /allograft Nerve exploration found intact ORIF Cortical allograft/cerclage
ORIF, open reduction internal fixation; IMN, intramedullary nail fixation
A total of eight major complications were recorded in five patients (26%) (Table III). Three patients (16%) required at least one revision procedure. One patient treated for nonunion after ORIF had gross loosening of the humeral component with resorption of the tuberosities two years post-operatively. She underwent onestage revision using a long stemmed humeral component and allografting. She rated the outcome as satisfactory 24 months post-operatively. Gross humeral loosening with an associated pathological fracture (oblique Type B) was also seen in a second patient two years after RSA. She underwent revision using a hemiarthroplasty tumour prosthesis owing to extensive humeral bone loss and rated her outcome as satisfactory 33 months post-operatively. Periprosthetic fractures occurred around a well-fixed humeral component in two patients, both of whom had been previously managed with an IMN. A completely displaced fracture (transverse Type A) was sustained three years post-operatively in one patient because of a fall. He declined further surgery. The second patient sustained a mildly displaced periprosthetic fracture (oblique Type B) five years post-operatively also due to a fall (Fig. 2). Revision was undertaken using a cemented long stemmed humeral component with cortical allograft and cerclage wire. This operation was complicated by a radial nerve palsy, and she subsequently fell again two months post-operatively sustaining another periprosthetic fracture (oblique Type B) at the supracondylar level. This was treated with dual-column ORIF, at which time the radial nerve was explored and found to be intact. The fracture was found united ten weeks after this procedure with subsequent resolution of the radial nerve palsy six months later. An intra-operative fracture occurred in one patient who had been treated previously with fixation using a plate and screws. After removal of the hardware, dislocation of the joint was performed and an iatrogenic fracture occurred through an empty screw hole in the shaft of the humerus while externally rotating the humerus. Supplementary cortical allograft and cerclage fixation was undertaken around a long stemmed humeral component. She rated the outcome as unsatisfactory 25 months after this procedure. A total of 11 patients rated their outcome as excellent (57.9%), four as good (21.1%), one as satisfactory (5.3%), and three as unsatisfactory (15.8%).
Discussion RSA is an appealing surgical option when managing patients with failed internal fixation, as its design is inherently less dependent on the integrity of the rotator cuff, and it allows the replacement of damaged articular surfaces. Using this form of treatment, our short-term results indicate that modest improvements can be reliably achieved in most patients. The patients had a mean improvement in ASES score of > 20 points, with significant improvement in ROM and reduction in pain. Measurements of forward elevation and abduction indicated that most patients could now elevate the arm to a level at or above the shoulder, with mean gains of 42° and 30°, respectively. Improvements in rotation were also seen, with mean gains of external rotation of > 10°, and increased mean internal rotation by two vertebral levels. Although no specific studies have addressed the use of RSA for treatment of failed internal fixation, studies relating to other sequelae of fractures can be extrapolated to this problem. Recently, Raiss et al29 examined the results of RSA for a heterogenous group of 32 patients with nonunion of a proximal humeral fracture previously treated either conservatively or surgically. Results showed a significant improvement in clinical outcome scores, as well as ROM, with mean forward flexion improving from 43° preoperatively to 110° post-operatively. There was no incidence of component loosening or periprosthetic fracture. However, they reported a rate of scapular notching of 50% and a rate of dislocation of 34%. Our study had an 11% notching rate and experienced no dislocations. However, we had a humeral loosening and periprosthetic fracture rate of 11% and 16%, respectively. A further operation was required in 28% of their cohort due to a complication. Significantly more complications and dislocations were seen in those patients whose tuberosities were resected at the time of RSA, with the authors recommending preservation of the tuberosities. Levy et al33 reported the use of a RSA in the treatment of failed hemiarthroplasty for a proximal humeral fracture in 29 patients. They noted significant improvements in the mean ASES and SST scores of 29.8 and 1.7 points, respectively. The mean forward elevation and abduction also improved (34.6° and 36.3°, respectively). However, mean external rotation (6.4°) failed to show significant improvement. Our findings THE BONE & JOINT JOURNAL
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Fig. 2a
Fig. 2b
Fig. 2d
Fig. 2e
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Fig. 2c
Fig. 2f
Radiographs showing periprosthetic fracture in 52-year-old female patient a) with failed intramedullary nail fixation, b) immediate post-operative anteroposterior radiograph after revision with reverse shoulder arthroplasty, c) five years after revision; she sustained an oblique Type B periprosthetic fracture after a fall. There is heterotopic ossification around the proximal humerus. d) An immediate post-operative radiograph after revision using a long stemmed humeral component supplemented with cortical allografting. e) Two months later, she fell again sustaining a second periprosthetic fracture at the level of the distal humerus. The humeral component was found to be stable. f) Anteroposterior radiograph showing dual-column ORIF of the second fracture.
were similar, with the notable exception of significantly improved rotation. Of note, however, is that eight shoulders required the use of a proximal humeral allograft due to extensive proximal bone loss, which probably influenced the improvements seen in rotation. Similar to our study, they reported a rate of complications of 28%. Willis et al34 reviewed 16 patients who underwent a RSA for management of malnunion of proximal humeral fractures which had been initially treated conservatively. The greater tuberosity was not osteotomised in any patient, even in those with severe malunion of a tuberosity, preferring to accept its malaligned position. Overall, all patients rated their final outcome as satisfactory or better, at shortterm follow-up. The mean ASES and SST scores improved VOL. 97-B, No. 7, JULY 2015
significantly (35 and three points, respectively), as did all mean ROM (forward elevation 52°, abduction 57°, external rotation 25° and internal rotation three vertebral levels). These results show slightly greater improvements in all functional measures than in our study. The inferior results seen in our patients probably relate to the difficulties in performing revision surgery with removal of implants. A relatively high rate of major complications occurred, requiring further surgery in three (16%) of our patients. Two periprosthetic fractures occurred in patients who had previously been treated with an IMN. We speculate that the empty holes from the distal interlocking screws created a stress riser from which a fracture propagated. One intra-operative fracture occurred while surgically dislocating the glenohumeral
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joint, with the fracture propagating through an empty shaft screw hole. We now dislocate the glenohumeral joint prior to removal of implants to reduce the risk of iatrogenic fracture. No patients had a dislocation and the rate of scapular notching (11%) was low. The RSA used in this study has a lateralised centre-of-rotation, which previous studies have shown to have a low rate of notching.33,34 Limitations of this study include its retrospective nature, the relatively small sample size and lack of long-term followup. The strengths include the fact that it was performed at a single institution by a high-volume fellowship trained shoulder surgeon. This served to decrease variability in surgical technique and improve clinical outcomes. Moreover, a single RSA was used. Our rationale for using a RSA stems from the technical difficulties in being able to balance the glenohumeral joint with a traditional nonconstrained prosthesis reliably, due to extensive fibrosis of the rotator cuff and frequent malunion or nonunion of the tuberosities. Previous authors have shown unpredictable results using a nonconstrained prosthesis.35,36 Many factors should be considered before proceeding with a RSA for failed internal fixation. Specifically, younger patients should be considered candidates for hardware removal, revision ORIF, or even hemiarthroplasty before performing a RSA, given the concerns regarding the longterm survival of a RSA. In certain patients however, we have found RSA to give reasonable and reliable results when managing this difficult problem. Author contributions: M. M. Hussey: Study design, Data collection, Data analysis, Writing the paper. S. E. Hussey: Data analysis, Editing the paper. M. A. Mighell: Study design, Performing surgeries, Writing the paper. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by J. Scott and first proof edited by G. Scott.
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