Musculoskelet Surg (2014) 98 (Suppl 1):S5–S13 DOI 10.1007/s12306-014-0321-4
ORIGINAL ARTICLE
Reverse shoulder arthroplasty without subscapularis repair for the treatment of proximal humeral fractures in the elderly F. A. Grassi • I. Zorzolo
Received: 18 January 2014 / Accepted: 26 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Purpose The aim of this study was to evaluate the shortterm results after reverse shoulder arthroplasty (RSA) for proximal humeral fractures in elderly patients. Methods The same surgical technique was adopted in all patients: the procedure was performed through a deltopectoral approach, the subscapularis was always resected, and a positioning jig was used to implant the cemented humeral component in the desired height and in 20° of retroversion. Nineteen consecutive patients, affected by complex fractures of the proximal humerus, were operated in a 3-year period by the same surgeon at a single institution. All the patients were female, with a mean age of 75 years (range 70–83). Results Fifteen patients were evaluated at an average follow-up of 22 months (range 12–46 months). A postoperative infected hematoma was the only recorded complication. The absolute Constant score averaged 45.7 (range 19–69), while the relative and normalized scores averaged 65.1 (range 33–97) and 58.5 (range 24–91), respectively. The average Shoulder Pain and Disability Index (SPADI) score was 39 (range 6–89). X-rays showed healing of the greater tuberosity to the humeral diaphysis in nine shoulders. Conclusions RSA is an established treatment option for elderly patients with proximal humeral fractures, particularly when general and local conditions are predictive of failure with hemiarthroplasty. Even though clinical results
F. A. Grassi (&) I. Zorzolo S.C. Ortopedia e Traumatologia, A.O.U. ‘‘Maggiore della Carita`’’, Universita` degli studi del Piemonte Orientale ‘‘A. Avogadro’’, Novara, Italy e-mail: [email protected]
were quite variable in this series of patients, the adoption of a standardized surgical technique allowed to minimize postoperative complications. Subscapularis repair does not seem a critical factor for preventing implant dislocation, but its influence on functional results needs further investigation. Keywords Reverse shoulder arthroplasty Proximal humeral fractures Subscapularis Elderly
Introduction Shoulder replacement for the treatment of proximal humeral fractures is still a controversial topic, mainly for the unpredictability and wide variability of functional results reported in the literature. Hemiarthroplasty (HA) has been the only implant available for many years, but now reverse shoulder arthroplasty (RSA) represents an alternative option for these injuries. There are two main factors that justify the use of the reverse prosthesis in fractures, particularly in elderly patients: a less demanding rehabilitation program and the preservation of a fixed fulcrum for deltoid action in case of cuff failure. However, RSA seems to have a higher rate of postoperative complications than HA, and there is concern about the results in the medium and long term due to the occurrence of scapular notching and the lack of valid alternatives in case of failure [1]. The surgical technique of RSA in fracture cases is quite variable from surgeon to surgeon. The main differences are related to the surgical approach (anterior deltopectoral vs. superior transdeltoid), the management of the subscapularis tendon, the version of the humeral component and soft tissue tension after reduction.
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In this study, we describe a standardized implant technique that was adopted in a consecutive series of 19 elderly patients; clinical and radiographic results were evaluated at a minimum follow-up of 1 year.
Materials and methods During a 3-year period (June 2009–June 2012), 19 patients aged C70 years underwent RSA for the treatment of proximal humeral fractures at the authors’ Institution. All the patients were women, with an average age of 75 years (range 70–83; SD ± 3.8) at the time of injury. The surgical procedure was performed after a minimum of 4 days and a maximum of 14 days from trauma (mean 8.2 ± 3.06). The dominant arm was involved in 16 patients. Criteria of exclusion for treatment included severe cognitive impairment, pathologic fractures or comorbidities entailing an unacceptable anesthesiological risk (ASA [ 4). None of the patients were institutionalized at the time of hospital admission. Most common medical comorbidities included hypertension (ten patients), cardiac arrhythmias (seven patients) and diabetes (four patients). Fractures were classified according to Neer’s criteria: there were 4 three-part fractures, 9 four-part fractures, 3 three-part (1 with a concomitant fracture of the anterior glenoid) and 2 four-part fracture dislocations, and 1 headsplitting fracture with diaphyseal extension. Two patients presented with complications related to the fracture. An acute occlusion of the subclavian artery, caused by a displaced bony fragment, occurred in one patient and required an emergency surgical intervention consisting in sole removal of the bone fragments and limb revascularization; the reverse prosthesis was then implanted after 8 days. Another patient suffered a traumatic injury of the axillary nerve (neuropraxia) with temporary deltoid palsy and skin hypoesthesia in the deltoid region; RSA was performed after 9 days, when neurological recovery became evident. Perioperative antibiotic and antithromboembolic prophylaxis was carried out in all patients according to standardized protocols. The same surgical procedure was performed by a single experienced surgeon (F.G.) on all the patients of this series, using the Delta Xtend Reverse Shoulder System (DePuy Synthes, Warsaw, USA) with the cemented humeral component. Intraoperatively, a massive rotator cuff tear was detected in nine patients (47 %); the teres minor tendon was always present.
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Passive motion was started on the first postoperative day, and the patients were allowed to use the operated shoulder for activities of daily living after 1 month. All the patients but one were assisted in the rehabilitation program by a physiotherapist. At follow-up, the patients were evaluated clinically and radiographically. The absolute, relative and normalized Constant scores [2] and the Shoulder Pain and Disability Index (SPADI) score [3] were used for the clinical evaluation. We chose the SPADI score for its simplicity, since other questionnaires included items that could hardly be administered or applied to our study population. X-rays were taken in A-P view in external rotation and A-P view on the scapular plane (true A-P) in order to evaluate tuberosity healing and inferior scapular notching. Radiographs were evaluated by an independent observer. A possible correlation between clinical outcome and radiographic appearance of the tuberosity fragment (healed vs. resorbed) was also investigated at follow-up. Surgical technique The patient is placed on the operative table in a beach-chair position; the shoulder is covered by an adhesive surgical drape with iodine. The skin incision starts from the coracoid tip and runs distally and laterally for about 10 cm to the middle deltoid region, keeping away from the anterior axillary fold. A standard deltopectoral approach is used for exposing the fracture site. The tendon of the long head of the biceps, if present, is sectioned and tenodesed at the level of the pectoralis major tendon. The lesser tuberosity and the subscapularis tendon (with the anterior capsule) are isolated and resected; the anterior circumflex vessels are ligated in order to avoid bleeding. Once the anterior tissues are removed, the gleno-humeral joint and the remaining fracture fragments of the proximal humerus are easily exposed. The articular fragment of the humeral head is removed, while the greater tuberosity with the posterior cuff is carefully preserved. The supraspinatus tendon is usually resected to avoid superior pull on the tuberosity fragment. The glenoid components of the reverse prosthesis are implanted according to the standard technique: reaming of the glenoid, baseplate implantation and fixation with screws, glenosphere assembling on the baseplate. The humeral canal is reamed manually until a delicate bite is felt on the inner wall of the humeral shaft. A specifically designed Positioning Jig (DePuy Synthes, Warsaw, USA) is applied to the proximal part of the diaphyseal fragment in order to assist the surgeon in implanting the humeral component in the desired degree of retroversion and height (Fig. 1).
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Fig. 1 Positioning Jig (DePuy Synthes, USA). a The jig consists of a big clamp (large arrow) that grasps the diaphysis, and a small clamp (thin arrow) fixed to the prosthesis. A sliding mechanism (dotted
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arrow) allows downward and upward movements of the stem for length assessment. b Intraoperative view of the jig holding the trial humeral component
Fig. 2 Pictures showing intraoperative evaluation of shoulder motion and stability with the trial humeral component held by the jig (arrows): a abduction and external rotation (the frame is a magnification of the detail); b forward elevation
In all the patients of this series, the humeral component was placed in 20° of retroversion. The preferred height was assessed empirically by reducing the trial humeral component, held securely by the jig, into the glenosphere: in this way, joint stability and mobility, as well as soft tissue tension, were easily evaluated before implantation of the definitive humeral stem (Fig. 2). After removal of the trial component, the jig is left in place in order to allow a precise reproduction of the
predefined position with the definitive stem. If fixation is achieved with cement (as was always done in this series of patients), the jig is useful for preventing accidental displacement of the humeral component while the methacrylate is polymerizing. After humeral cup assembly and joint reduction, the greater tuberosity with the posterior cuff is firmly reattached to the prosthesis and to the humeral diaphysis by means of high resistance sutures (Fig. 3). Autologous bone
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chips, harvested from the humeral head, can be placed at the interface between the tuberosity and the diaphysis in order to enhance bone healing. A suction drain is placed deeply into the wound before subcutaneous and skin closure.
At follow-up, pain was absent in one patient, mild in nine patients and moderate in four patients; one patient complained of severe pain. Active forward elevation of the shoulder averaged 111° ± 33.1° (range 50–160). Only two patients (11 %) reported a complete recovery of shoulder function to their preoperative level. The mean absolute Constant–Murley score was 45.7 ± 15.6 (range 19–69); the mean relative score, calculated by comparison with the contralateral shoulder, was 65.1 ± 19.7 (range 33–97); and the normalized score, based on gender and age [4], was 58.5 ± 20.5 (range 24–91). A detailed description of the Constant–Murley scores, measured on the 15 patients evaluated at follow-up, is reported in Table 1. The average SPADI score—where 0 is the best and 100 is the worst—was 39 ± 22.1 (range 6–89). The pain score ranged from 4 to 82 (mean 30.4 ± 20.4), while the disability score ranged from 3.75 to 93.8 (mean 41.2 ± 26.6). Radiographs showed healing of the greater tuberosity to the humeral diaphysis in nine shoulders (60 %) (Fig. 4), while in six patients, complete or partial resorption of the tuberosity fragments had occurred. Scapular notching was found in seven cases (47 %): they were all classified as Grade 1 according to Nerot [5] and in five shoulders were accompanied by bony spurs of the scapular neck. Heterotopic ossification at the level of the inferior gleno-humeral capsule was present in four patients (27 %). No periprosthetic radiolucencies or evidence of component migration could be detected (Table 2). There was no correlation between the radiographic appearance of the tuberosity fragment and the clinical result: tuberosity healing did not imply higher Constant scores as well as tuberosity resorption did not result in functional failures (Table 2; Figs. 5, 6).
Results
Discussion
At an average follow-up of 22 months (range 12–46), 15 patients (79 %) were evaluated clinically and radiographically; one patient was interviewed by phone, while three patients were unable or unwilling to undergo the scheduled evaluation. No patient died during the study period, but two patients (not evaluated at follow-up) had been institutionalized for cognitive impairment in the time interval between hospital discharge and follow-up. The only complication observed was an infected hematoma, diagnosed 5 days after surgery and caused by Proteus mirabilis. The infection was successfully treated by surgical debridement, replacement of the movable components (glenosphere and humeral cup) and systemic antibiotics for 6 weeks.
The use of RSA for the surgical treatment of proximal humeral fractures has been proposed to overcome the limited therapeutic efficacy of HA, as well as of fixation techniques, in elderly patients [6–10]. It is well know that several factors influence the functional outcome of a shoulder replacement in fracture cases: tuberosity comminution, rotator cuff conditions, individual surgical experience and patient’s compliance to rehabilitation. In elderly patients, the loss of shoulder function after surgery is frequent, because in the elderly population, the coexistence of negative prognostic factors is common. RSA implies some potential advantages in this scenario: the prosthesis does not rely on cuff integrity for deltoid function, the implant technique is simpler than HA, and
Fig. 3 Intraoperative view at the end of the procedure with the shoulder in external rotation: the greater tuberosity and the posterior cuff have been reattached to the prosthesis and the humeral diaphysis (arrow), while the anterior aspect of the implant is left uncovered since the subscapularis has not been repaired (arrow point)
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Table 1 Constant scores recorded at follow-up Patient (age)
Absolute Pain
ADL
ROM
Activity level
Hand position
Elevation
Abduction
ER
IR
Strength
Total
Relative
Normalized
91
G.I. (77)
10
6
10
10
10
10
10
2
68
97
M.L. (71)
10
6
6
8
8
8
2
4
52
70
66
B.M. (77)
5
0
4
4
4
2
0
0
19
33
24
T.L. (74)
10
6
8
8
8
8
6
2
56
77
71
G.C. (80)
10
2
6
6
4
4
2
2
36
49
48
C.A. (76)
5
6
6
8
6
4
6
10
51
70
64
S.C.A. (77)
15
6
6
4
4
2
8
3
48
67
61
P.S. (71)
10
6
8
8
8
8
4
2
54
79
68
P.M. (73)
5
2
8
8
6
4
4
2
39
51
49
5
2
8
8
4
4
2
2
35
49
R.A.M. (70) G.G. (72)
a
44 a
10
2
6
4
4
2
2
2
32
(89)
S.A. (83)
10
6
10
10
8
10
6
2
62
85
83
C.R. (72)
10
6
10
10
10
10
8
5
69
88
87
C.G. (72) P.P. (79)
5 5
2 0
8 4
8 4
6 2
8 2
6 2
2 0
45 19
62 34
57 24
Average (fracture)
8.3
3.9
7.2
7.2
6.1
5.7
4.5
2.7
45.7 – 15.6
65.1 – 19.7
58.5 – 20.5
8.7
9.3
7.9
4.6
68.3
–
87.4
11.1 Average (contralateral)
13.3
5.5 15.2
41
23.5 9.7
9.3 35.2
Average total scores of the studied population are in bold a
HA for fracture in the contralateral side (relative score not included for average computation)
Fig. 4 Four-part fracture dislocation of the proximal humerus treated with RSA in a 77-year-old patient. a Preoperative radiograph of the shoulder; b postoperative control; c 3 years after the operation, A-P view in external rotation shows tuberosity healing (arrow)
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Table 2 Radiographic findings at follow-up and corresponding Constant scores Patient (age)
Radiographic findings
Absolute Constant score
Tuberosity
Scapular notch grade
Heterotopic ossifications
G.I. (77)
Healed
1
–
68
M.L. (71)
Healed
1
–
52
B.M. (77)
Healed
0
Yes
19
T.L. (74)
Healed
0
–
56
G.C. (80)
Healed
0
–
36
C.A. (76)
Resorbed
1 (?spur)
–
51
S.C.A. (77)
Healed
1 (?spur)
Yes
48
P.S. (71)
Healed
1 (?spur)
–
54
P.M. (73)
Healed
0
Yes
39
R.A.M. (70)
Resorbed
1 (?spur)
–
35
G.G. (72)
Partially resorbed
0
Yes
32
S.A. (83)
Resorbed
0
–
62
C.R. (72) C.G. (72)
Resorbed Partially resorbed
0 0
– –
69 45
P.P. (79)
Healed
1 (?spur)
–
19
also the rehabilitation program is less demanding for the patient. Several studies have compared the short-term clinical outcomes of HA and RSA for the treatment of proximal humeral fractures [6, 11–13]. Some authors did not highlight striking differences between the two procedures, while others reported better results with RSA, particularly when more recent implant designs were used. In a review of the literature on this topic, Namdari et al. [14] concluded that subjective and objective outcomes of the two techniques were similar, but RSA was associated with a higher risk of postoperative complications. The difficulty in comparing results between HA and RSA—and generally between all treatment modalities for proximal humeral fractures—is related to a number of factors: no prospective randomized methodology, bias related to treatment choice, differences in surgical techniques, follow-up time and outcome tools. In a previous study published in 2005, the senior author (F.G.) reported the results achieved in a series of 24 patients C70 years, treated with HA for fractures of the proximal humerus and evaluated at an average follow-up of 5 years [15]. The average Constant scores (absolute, relative and normalized) were higher than the values recorded in this study with RSA: 55.6, 75.4 and 79.1 versus 45.7,
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66.7 and 58.5, respectively. However, the relevance of this comparison should be judged carefully and is probably misleading, since the indications for HA at that time were different from the current indications for RSA. The choice between HA and RSA should rely on a careful preoperative evaluation of both the general conditions of the patient and the anatomical condition of the shoulder. Patients with good bone stock, intact cuff and high functional demands are ideal candidates for HA, while patients with tuberosity fragmentation related to poor bone stock, suspect cuff tears and low functional demands should be treated by RSA. Age is not the exclusive parameter to consider in decision making, even though RSA is usually performed in patients older than 70 years, while HA is preferred in younger individuals. Recently, Mata-Fink et al. [16] carried out a systematic review of the published studies on RSA for proximal humeral fractures in elderly patients. The clinical results of our study can be compared with six studies, in which active forward elevation and absolute Constant score were measured (Table 3). The average values are comparable in terms of active elevation, but the Constant score in our study is consistently lower than most of the scores reported by the other authors. This might reflect methodological differences in measuring the different parameters included in this score [20]. Similarly to HA, the clinical outcomes with RSA in fractures are quite variable. In our experience, pain relief with RSA was not as satisfactory as with HA: only one out of fifteen patients declared to be completely pain-free at follow-up. It is difficult to explain this observation, because there was scant objective evidence or physical findings to explain the symptoms. In a long-term retrospective study on RSA (Delta III, DePuy) for fractures, Cazeunueve and Cristofari [1] found an association between increased pain and scapular notching when associated with abnormal humeral radiographic images. Due to the short follow-up, it was not possible to highlight any radiographic findings that could explain the presence of pain in this series of patient. Psychological and social issues should also be considered as a possible cause of persistent shoulder discomfort, because many elderly patients feel depressed and lonely. This emotional malaise not only has negative repercussions on compliance to treatment, but also affects pain perception in the long term [21]. The functional outcomes show that recovery of active motion and strength with RSA in fractures is unpredictable; therefore, the patients should be informed that return to pre-injury levels of activity is unlikely. In contrast to what reported for HA, anatomical healing of the tuberosities in RSA is not a critical factor for improving the functional results as well as for preventing functional disasters. This
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Fig. 5 a Four-part fracture in a 79-year-old patient. b Radiograph at follow-up (2 years) shows healing of an osteopenic tuberosity to the humeral diaphysis (arrow); absolute Constant score is 19
Fig. 6 a Three-part fracture with tuberosity fragmentation in a 72-year-old patient. b Radiograph at follow-up (18 months) shows tuberosity resorption (arrow); absolute Constant score is 69
series of patients did not exhibit a positive correlation between tuberosity healing and functional outcome. Other authors compared RSA function with or without tuberosity repair and concluded that better results, especially with regard to external rotation, were observed when consolidation of the tuberosities had occurred [22].
The surgical technique performed for RSA in proximal humeral fractures differs from surgeon to surgeon. In this study, we present a standardized and reproducible procedure through a deltopectoral approach: its main goal is to facilitate correct positioning of the humeral component.
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Table 3 Comparison of clinical results reported for RSA in fractures n
Age (years)
Followup (months)
Active forward elevation
Absolute Constant score
Sirveaux et al. [17]
15
78
46
107°
55
Bufquin et al. [7]
43
78
22
97°
44
Klein et al. [18]
20
75
33
122.6°
67.85
Gallinet et al. [12]
19
74.8
12.4
97.5°
53
Reitman and Kerzhner [10]
13
70
33.3
125°
67
Valenti et al. [19]
30
78
22.5
112°
54.9
Average
23.3
75.6
28.2
110.2°
56.9
Current study
19
75
22
111°
45.7
The lack of reliable anatomical landmarks in some fracture patterns as well as the conflicting opinions about proper orientation of the humeral component might raise intraoperative doubts about the prosthesis position. The criteria described in the literature for establishing the correct height of the humeral component in RSA rely on pectoralis major tendon insertion (approximately 5.5 cm caudad to the top of the humeral head) or on anatomical matching of the tuberositiy fragments on the diaphysis [9]. As regards version, some authors propose to implant the humeral component in neutral version [23], as described originally by Grammont, while others suggest to reproduce the anatomical retroversion [24]. In our technique, the most suitable position of the humeral component can be assessed empirically during the surgical procedure by means of an extramedullary instrument that stabilizes the trial implant to the diaphysis. Without performing any additional dissection, it is possible to evaluate shoulder stability, mobility and soft tissue tension before implanting the definitive prosthesis. Another relevant feature of this technique is the resection of the subscapularis tendon together with the lesser tuberosity. There are conflicting opinions about the role of the subscapularis on RSA stability: some authors have related the deltopectoral approach and an irreparable subscapularis to higher rates of RSA dislocation [25], while others have not found any correlation [26]. This issue has not been discussed for RSA in fractures, but in our experience, neither the deltopectoral approach nor subscapularis excision was associated with the onset of instability.
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The role of subscapularis repair on the functional outcome was not investigated in this study and should be brought into focus by randomized controlled trials. Nonetheless we suppose, in agreement with Routman [27], that subscapularis repair may have biomechanical drawbacks on RSA, especially for the potential loss of external rotation. Owing to humeral lowering in RSA, the anterior tension resulting from reconstruction of the lesser tuberosity/subscapularis can jeopardize recovery of external rotation in elderly patients, who already exhibit muscular weakness if not extensive rotator cuff tears. In all the patients of this series, the humeral component was implanted in 20° of retroversion with the intent to decrease the risk of dislocation and preserve external rotation [28]. It was our belief that this orientation was a reasonable and well-advised choice, using the deltopectoral approach and excising the subscapularis. Results on implant stability were excellent, but it is not possible to state if this was the most appropriate position for achieving the best functional outcome. RSA for proximal humeral fractures allows several variations in the surgical technique: future studies should clarify whether more satisfactory and reproducible results are more likely to be achieved by replicating a standardized implant procedure or rather by adopting different solutions on an individual basis. Conflict of interest None of the authors received payments or services, either directly or indirectly (i.e., via his or her Institution), from a third party in support of any aspect of this work. Federico A. Grassi receives consulting fees from DePuy Synthes. Ilaria Zorzolo has not received any financial payments or other benefits from any commercial entity related to the subject of this article. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrollment in the study and to the inclusion in this article of information that could potentially lead to their identification. Human and Animal Rights The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.
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S13 17. Sirveaux F, Navez G, Favard L, Boileau P, Walch G, Mole D (2006) Reverse prosthesis for acute proximal humerus fracture, the multicentric study. In: Walch G, Boileau P, Mole D (eds) Reverse shoulder arthroplasty: clinical results, complications, revisions. Sauramps Medical, Montpellier (France), pp 73–80 18. Klein M, Juschka M, Hinkenjann B, Scherger B, Ostermann PA (2008) Treatment of comminuted fractures of the proximal humerus in elderly patients with the Delta III reverse shoulder prosthesis. J Orthop Trauma 22:698–704. doi:10.1097/BOT. 0b013e31818afe40 19. Valenti P, Katz D, Kilinc A, Elkholti K, Gasiunas V (2012) Midterm outcome of reverse shoulder prostheses in complex proximal humeral fractures. Acta Orthop Belg 78:442–449 20. Constant CR, Gerber C, Emery RJ, Sojbjerg JO, Gohlke F, Boileau P (2008) A review of the Constant score: modifications and guidelines for its use. J Shoulder Elbow Surg 17:355–361. doi:10.1016/j.jse.2007.06.022 21. Roh YH, Lee BK, Noh JH, Oh JH, Gong HS, Baek GH (2012) Effect of depressive symptoms on perceived disability in patients with chronic shoulder pain. Arch Orthop Trauma Surg 132:1251–1257. doi:10.1007/s00402-012-1545-0 22. Gallinet D, Adam A, Gasse N, Rochet S, Obert L (2013) Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. J Shoulder Elbow Surg 22:38–44. doi:10.1016/j.jse.2012.03.011 23. Favre P, Sussmann PS, Gerber C (2010) The effect of component positioning on intrinsic stability of the reverse shoulder arthroplasty. J Shoulder Elbow Surg 19:550–556. doi:10.1016/j.jse. 2009.11.044 24. Nalbone L, Adelfio R, D’Arienzo M, Ingrassia T, Nigrelli V, Zabbara F, Paladini P, Campi F, Pellegrini A, Porcellini G (2013) Optimal positioning of the humeral component in the reverse shoulder prosthesis. Musculoskelet Surg. doi:10.1007/s12306013-0274-z 25. Edwards TB, Williams MD, Labriola JE, Elkousy HA, Gartsman GM, O’Connor DP (2009) Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty. J Shoulder Elbow Surg 18:892–896. doi:10.1016/j.jse.2008.12. 013 26. Clark JC, Ritchie J, Song FS, Kissenberth MJ, Tolan SJ, Hart ND, Hawkins RJ (2012) Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg 21:36–41. doi:10.1016/j.jse.2011.04.009 27. Routman HD (2013) The role of subscapularis repair in reverse total shoulder arthroplasty. Bull Hosp Jt Dis 71(Suppl 2):S108– S112 28. Stephenson DR, Oh JH, McGarry MH, Rick Hatch GF, Lee TQ (2011) Effect of humeral component version on impingement in reverse total shoulder arthroplasty. J Shoulder Elbow Surg 20:652–658. doi:10.1016/j.jse.2010.08.020
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ORIGINAL ARTICLE
Reverse shoulder arthroplasty without subscapularis repair for the treatment of proximal humeral fractures in the elderly F. A. Grassi • I. Zorzolo
Received: 18 January 2014 / Accepted: 26 February 2014 / Published online: 23 March 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Purpose The aim of this study was to evaluate the shortterm results after reverse shoulder arthroplasty (RSA) for proximal humeral fractures in elderly patients. Methods The same surgical technique was adopted in all patients: the procedure was performed through a deltopectoral approach, the subscapularis was always resected, and a positioning jig was used to implant the cemented humeral component in the desired height and in 20° of retroversion. Nineteen consecutive patients, affected by complex fractures of the proximal humerus, were operated in a 3-year period by the same surgeon at a single institution. All the patients were female, with a mean age of 75 years (range 70–83). Results Fifteen patients were evaluated at an average follow-up of 22 months (range 12–46 months). A postoperative infected hematoma was the only recorded complication. The absolute Constant score averaged 45.7 (range 19–69), while the relative and normalized scores averaged 65.1 (range 33–97) and 58.5 (range 24–91), respectively. The average Shoulder Pain and Disability Index (SPADI) score was 39 (range 6–89). X-rays showed healing of the greater tuberosity to the humeral diaphysis in nine shoulders. Conclusions RSA is an established treatment option for elderly patients with proximal humeral fractures, particularly when general and local conditions are predictive of failure with hemiarthroplasty. Even though clinical results
F. A. Grassi (&) I. Zorzolo S.C. Ortopedia e Traumatologia, A.O.U. ‘‘Maggiore della Carita`’’, Universita` degli studi del Piemonte Orientale ‘‘A. Avogadro’’, Novara, Italy e-mail: [email protected]
were quite variable in this series of patients, the adoption of a standardized surgical technique allowed to minimize postoperative complications. Subscapularis repair does not seem a critical factor for preventing implant dislocation, but its influence on functional results needs further investigation. Keywords Reverse shoulder arthroplasty Proximal humeral fractures Subscapularis Elderly
Introduction Shoulder replacement for the treatment of proximal humeral fractures is still a controversial topic, mainly for the unpredictability and wide variability of functional results reported in the literature. Hemiarthroplasty (HA) has been the only implant available for many years, but now reverse shoulder arthroplasty (RSA) represents an alternative option for these injuries. There are two main factors that justify the use of the reverse prosthesis in fractures, particularly in elderly patients: a less demanding rehabilitation program and the preservation of a fixed fulcrum for deltoid action in case of cuff failure. However, RSA seems to have a higher rate of postoperative complications than HA, and there is concern about the results in the medium and long term due to the occurrence of scapular notching and the lack of valid alternatives in case of failure [1]. The surgical technique of RSA in fracture cases is quite variable from surgeon to surgeon. The main differences are related to the surgical approach (anterior deltopectoral vs. superior transdeltoid), the management of the subscapularis tendon, the version of the humeral component and soft tissue tension after reduction.
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In this study, we describe a standardized implant technique that was adopted in a consecutive series of 19 elderly patients; clinical and radiographic results were evaluated at a minimum follow-up of 1 year.
Materials and methods During a 3-year period (June 2009–June 2012), 19 patients aged C70 years underwent RSA for the treatment of proximal humeral fractures at the authors’ Institution. All the patients were women, with an average age of 75 years (range 70–83; SD ± 3.8) at the time of injury. The surgical procedure was performed after a minimum of 4 days and a maximum of 14 days from trauma (mean 8.2 ± 3.06). The dominant arm was involved in 16 patients. Criteria of exclusion for treatment included severe cognitive impairment, pathologic fractures or comorbidities entailing an unacceptable anesthesiological risk (ASA [ 4). None of the patients were institutionalized at the time of hospital admission. Most common medical comorbidities included hypertension (ten patients), cardiac arrhythmias (seven patients) and diabetes (four patients). Fractures were classified according to Neer’s criteria: there were 4 three-part fractures, 9 four-part fractures, 3 three-part (1 with a concomitant fracture of the anterior glenoid) and 2 four-part fracture dislocations, and 1 headsplitting fracture with diaphyseal extension. Two patients presented with complications related to the fracture. An acute occlusion of the subclavian artery, caused by a displaced bony fragment, occurred in one patient and required an emergency surgical intervention consisting in sole removal of the bone fragments and limb revascularization; the reverse prosthesis was then implanted after 8 days. Another patient suffered a traumatic injury of the axillary nerve (neuropraxia) with temporary deltoid palsy and skin hypoesthesia in the deltoid region; RSA was performed after 9 days, when neurological recovery became evident. Perioperative antibiotic and antithromboembolic prophylaxis was carried out in all patients according to standardized protocols. The same surgical procedure was performed by a single experienced surgeon (F.G.) on all the patients of this series, using the Delta Xtend Reverse Shoulder System (DePuy Synthes, Warsaw, USA) with the cemented humeral component. Intraoperatively, a massive rotator cuff tear was detected in nine patients (47 %); the teres minor tendon was always present.
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Passive motion was started on the first postoperative day, and the patients were allowed to use the operated shoulder for activities of daily living after 1 month. All the patients but one were assisted in the rehabilitation program by a physiotherapist. At follow-up, the patients were evaluated clinically and radiographically. The absolute, relative and normalized Constant scores [2] and the Shoulder Pain and Disability Index (SPADI) score [3] were used for the clinical evaluation. We chose the SPADI score for its simplicity, since other questionnaires included items that could hardly be administered or applied to our study population. X-rays were taken in A-P view in external rotation and A-P view on the scapular plane (true A-P) in order to evaluate tuberosity healing and inferior scapular notching. Radiographs were evaluated by an independent observer. A possible correlation between clinical outcome and radiographic appearance of the tuberosity fragment (healed vs. resorbed) was also investigated at follow-up. Surgical technique The patient is placed on the operative table in a beach-chair position; the shoulder is covered by an adhesive surgical drape with iodine. The skin incision starts from the coracoid tip and runs distally and laterally for about 10 cm to the middle deltoid region, keeping away from the anterior axillary fold. A standard deltopectoral approach is used for exposing the fracture site. The tendon of the long head of the biceps, if present, is sectioned and tenodesed at the level of the pectoralis major tendon. The lesser tuberosity and the subscapularis tendon (with the anterior capsule) are isolated and resected; the anterior circumflex vessels are ligated in order to avoid bleeding. Once the anterior tissues are removed, the gleno-humeral joint and the remaining fracture fragments of the proximal humerus are easily exposed. The articular fragment of the humeral head is removed, while the greater tuberosity with the posterior cuff is carefully preserved. The supraspinatus tendon is usually resected to avoid superior pull on the tuberosity fragment. The glenoid components of the reverse prosthesis are implanted according to the standard technique: reaming of the glenoid, baseplate implantation and fixation with screws, glenosphere assembling on the baseplate. The humeral canal is reamed manually until a delicate bite is felt on the inner wall of the humeral shaft. A specifically designed Positioning Jig (DePuy Synthes, Warsaw, USA) is applied to the proximal part of the diaphyseal fragment in order to assist the surgeon in implanting the humeral component in the desired degree of retroversion and height (Fig. 1).
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Fig. 1 Positioning Jig (DePuy Synthes, USA). a The jig consists of a big clamp (large arrow) that grasps the diaphysis, and a small clamp (thin arrow) fixed to the prosthesis. A sliding mechanism (dotted
S7
arrow) allows downward and upward movements of the stem for length assessment. b Intraoperative view of the jig holding the trial humeral component
Fig. 2 Pictures showing intraoperative evaluation of shoulder motion and stability with the trial humeral component held by the jig (arrows): a abduction and external rotation (the frame is a magnification of the detail); b forward elevation
In all the patients of this series, the humeral component was placed in 20° of retroversion. The preferred height was assessed empirically by reducing the trial humeral component, held securely by the jig, into the glenosphere: in this way, joint stability and mobility, as well as soft tissue tension, were easily evaluated before implantation of the definitive humeral stem (Fig. 2). After removal of the trial component, the jig is left in place in order to allow a precise reproduction of the
predefined position with the definitive stem. If fixation is achieved with cement (as was always done in this series of patients), the jig is useful for preventing accidental displacement of the humeral component while the methacrylate is polymerizing. After humeral cup assembly and joint reduction, the greater tuberosity with the posterior cuff is firmly reattached to the prosthesis and to the humeral diaphysis by means of high resistance sutures (Fig. 3). Autologous bone
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chips, harvested from the humeral head, can be placed at the interface between the tuberosity and the diaphysis in order to enhance bone healing. A suction drain is placed deeply into the wound before subcutaneous and skin closure.
At follow-up, pain was absent in one patient, mild in nine patients and moderate in four patients; one patient complained of severe pain. Active forward elevation of the shoulder averaged 111° ± 33.1° (range 50–160). Only two patients (11 %) reported a complete recovery of shoulder function to their preoperative level. The mean absolute Constant–Murley score was 45.7 ± 15.6 (range 19–69); the mean relative score, calculated by comparison with the contralateral shoulder, was 65.1 ± 19.7 (range 33–97); and the normalized score, based on gender and age [4], was 58.5 ± 20.5 (range 24–91). A detailed description of the Constant–Murley scores, measured on the 15 patients evaluated at follow-up, is reported in Table 1. The average SPADI score—where 0 is the best and 100 is the worst—was 39 ± 22.1 (range 6–89). The pain score ranged from 4 to 82 (mean 30.4 ± 20.4), while the disability score ranged from 3.75 to 93.8 (mean 41.2 ± 26.6). Radiographs showed healing of the greater tuberosity to the humeral diaphysis in nine shoulders (60 %) (Fig. 4), while in six patients, complete or partial resorption of the tuberosity fragments had occurred. Scapular notching was found in seven cases (47 %): they were all classified as Grade 1 according to Nerot [5] and in five shoulders were accompanied by bony spurs of the scapular neck. Heterotopic ossification at the level of the inferior gleno-humeral capsule was present in four patients (27 %). No periprosthetic radiolucencies or evidence of component migration could be detected (Table 2). There was no correlation between the radiographic appearance of the tuberosity fragment and the clinical result: tuberosity healing did not imply higher Constant scores as well as tuberosity resorption did not result in functional failures (Table 2; Figs. 5, 6).
Results
Discussion
At an average follow-up of 22 months (range 12–46), 15 patients (79 %) were evaluated clinically and radiographically; one patient was interviewed by phone, while three patients were unable or unwilling to undergo the scheduled evaluation. No patient died during the study period, but two patients (not evaluated at follow-up) had been institutionalized for cognitive impairment in the time interval between hospital discharge and follow-up. The only complication observed was an infected hematoma, diagnosed 5 days after surgery and caused by Proteus mirabilis. The infection was successfully treated by surgical debridement, replacement of the movable components (glenosphere and humeral cup) and systemic antibiotics for 6 weeks.
The use of RSA for the surgical treatment of proximal humeral fractures has been proposed to overcome the limited therapeutic efficacy of HA, as well as of fixation techniques, in elderly patients [6–10]. It is well know that several factors influence the functional outcome of a shoulder replacement in fracture cases: tuberosity comminution, rotator cuff conditions, individual surgical experience and patient’s compliance to rehabilitation. In elderly patients, the loss of shoulder function after surgery is frequent, because in the elderly population, the coexistence of negative prognostic factors is common. RSA implies some potential advantages in this scenario: the prosthesis does not rely on cuff integrity for deltoid function, the implant technique is simpler than HA, and
Fig. 3 Intraoperative view at the end of the procedure with the shoulder in external rotation: the greater tuberosity and the posterior cuff have been reattached to the prosthesis and the humeral diaphysis (arrow), while the anterior aspect of the implant is left uncovered since the subscapularis has not been repaired (arrow point)
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Table 1 Constant scores recorded at follow-up Patient (age)
Absolute Pain
ADL
ROM
Activity level
Hand position
Elevation
Abduction
ER
IR
Strength
Total
Relative
Normalized
91
G.I. (77)
10
6
10
10
10
10
10
2
68
97
M.L. (71)
10
6
6
8
8
8
2
4
52
70
66
B.M. (77)
5
0
4
4
4
2
0
0
19
33
24
T.L. (74)
10
6
8
8
8
8
6
2
56
77
71
G.C. (80)
10
2
6
6
4
4
2
2
36
49
48
C.A. (76)
5
6
6
8
6
4
6
10
51
70
64
S.C.A. (77)
15
6
6
4
4
2
8
3
48
67
61
P.S. (71)
10
6
8
8
8
8
4
2
54
79
68
P.M. (73)
5
2
8
8
6
4
4
2
39
51
49
5
2
8
8
4
4
2
2
35
49
R.A.M. (70) G.G. (72)
a
44 a
10
2
6
4
4
2
2
2
32
(89)
S.A. (83)
10
6
10
10
8
10
6
2
62
85
83
C.R. (72)
10
6
10
10
10
10
8
5
69
88
87
C.G. (72) P.P. (79)
5 5
2 0
8 4
8 4
6 2
8 2
6 2
2 0
45 19
62 34
57 24
Average (fracture)
8.3
3.9
7.2
7.2
6.1
5.7
4.5
2.7
45.7 – 15.6
65.1 – 19.7
58.5 – 20.5
8.7
9.3
7.9
4.6
68.3
–
87.4
11.1 Average (contralateral)
13.3
5.5 15.2
41
23.5 9.7
9.3 35.2
Average total scores of the studied population are in bold a
HA for fracture in the contralateral side (relative score not included for average computation)
Fig. 4 Four-part fracture dislocation of the proximal humerus treated with RSA in a 77-year-old patient. a Preoperative radiograph of the shoulder; b postoperative control; c 3 years after the operation, A-P view in external rotation shows tuberosity healing (arrow)
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Table 2 Radiographic findings at follow-up and corresponding Constant scores Patient (age)
Radiographic findings
Absolute Constant score
Tuberosity
Scapular notch grade
Heterotopic ossifications
G.I. (77)
Healed
1
–
68
M.L. (71)
Healed
1
–
52
B.M. (77)
Healed
0
Yes
19
T.L. (74)
Healed
0
–
56
G.C. (80)
Healed
0
–
36
C.A. (76)
Resorbed
1 (?spur)
–
51
S.C.A. (77)
Healed
1 (?spur)
Yes
48
P.S. (71)
Healed
1 (?spur)
–
54
P.M. (73)
Healed
0
Yes
39
R.A.M. (70)
Resorbed
1 (?spur)
–
35
G.G. (72)
Partially resorbed
0
Yes
32
S.A. (83)
Resorbed
0
–
62
C.R. (72) C.G. (72)
Resorbed Partially resorbed
0 0
– –
69 45
P.P. (79)
Healed
1 (?spur)
–
19
also the rehabilitation program is less demanding for the patient. Several studies have compared the short-term clinical outcomes of HA and RSA for the treatment of proximal humeral fractures [6, 11–13]. Some authors did not highlight striking differences between the two procedures, while others reported better results with RSA, particularly when more recent implant designs were used. In a review of the literature on this topic, Namdari et al. [14] concluded that subjective and objective outcomes of the two techniques were similar, but RSA was associated with a higher risk of postoperative complications. The difficulty in comparing results between HA and RSA—and generally between all treatment modalities for proximal humeral fractures—is related to a number of factors: no prospective randomized methodology, bias related to treatment choice, differences in surgical techniques, follow-up time and outcome tools. In a previous study published in 2005, the senior author (F.G.) reported the results achieved in a series of 24 patients C70 years, treated with HA for fractures of the proximal humerus and evaluated at an average follow-up of 5 years [15]. The average Constant scores (absolute, relative and normalized) were higher than the values recorded in this study with RSA: 55.6, 75.4 and 79.1 versus 45.7,
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66.7 and 58.5, respectively. However, the relevance of this comparison should be judged carefully and is probably misleading, since the indications for HA at that time were different from the current indications for RSA. The choice between HA and RSA should rely on a careful preoperative evaluation of both the general conditions of the patient and the anatomical condition of the shoulder. Patients with good bone stock, intact cuff and high functional demands are ideal candidates for HA, while patients with tuberosity fragmentation related to poor bone stock, suspect cuff tears and low functional demands should be treated by RSA. Age is not the exclusive parameter to consider in decision making, even though RSA is usually performed in patients older than 70 years, while HA is preferred in younger individuals. Recently, Mata-Fink et al. [16] carried out a systematic review of the published studies on RSA for proximal humeral fractures in elderly patients. The clinical results of our study can be compared with six studies, in which active forward elevation and absolute Constant score were measured (Table 3). The average values are comparable in terms of active elevation, but the Constant score in our study is consistently lower than most of the scores reported by the other authors. This might reflect methodological differences in measuring the different parameters included in this score [20]. Similarly to HA, the clinical outcomes with RSA in fractures are quite variable. In our experience, pain relief with RSA was not as satisfactory as with HA: only one out of fifteen patients declared to be completely pain-free at follow-up. It is difficult to explain this observation, because there was scant objective evidence or physical findings to explain the symptoms. In a long-term retrospective study on RSA (Delta III, DePuy) for fractures, Cazeunueve and Cristofari [1] found an association between increased pain and scapular notching when associated with abnormal humeral radiographic images. Due to the short follow-up, it was not possible to highlight any radiographic findings that could explain the presence of pain in this series of patient. Psychological and social issues should also be considered as a possible cause of persistent shoulder discomfort, because many elderly patients feel depressed and lonely. This emotional malaise not only has negative repercussions on compliance to treatment, but also affects pain perception in the long term [21]. The functional outcomes show that recovery of active motion and strength with RSA in fractures is unpredictable; therefore, the patients should be informed that return to pre-injury levels of activity is unlikely. In contrast to what reported for HA, anatomical healing of the tuberosities in RSA is not a critical factor for improving the functional results as well as for preventing functional disasters. This
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Fig. 5 a Four-part fracture in a 79-year-old patient. b Radiograph at follow-up (2 years) shows healing of an osteopenic tuberosity to the humeral diaphysis (arrow); absolute Constant score is 19
Fig. 6 a Three-part fracture with tuberosity fragmentation in a 72-year-old patient. b Radiograph at follow-up (18 months) shows tuberosity resorption (arrow); absolute Constant score is 69
series of patients did not exhibit a positive correlation between tuberosity healing and functional outcome. Other authors compared RSA function with or without tuberosity repair and concluded that better results, especially with regard to external rotation, were observed when consolidation of the tuberosities had occurred [22].
The surgical technique performed for RSA in proximal humeral fractures differs from surgeon to surgeon. In this study, we present a standardized and reproducible procedure through a deltopectoral approach: its main goal is to facilitate correct positioning of the humeral component.
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Table 3 Comparison of clinical results reported for RSA in fractures n
Age (years)
Followup (months)
Active forward elevation
Absolute Constant score
Sirveaux et al. [17]
15
78
46
107°
55
Bufquin et al. [7]
43
78
22
97°
44
Klein et al. [18]
20
75
33
122.6°
67.85
Gallinet et al. [12]
19
74.8
12.4
97.5°
53
Reitman and Kerzhner [10]
13
70
33.3
125°
67
Valenti et al. [19]
30
78
22.5
112°
54.9
Average
23.3
75.6
28.2
110.2°
56.9
Current study
19
75
22
111°
45.7
The lack of reliable anatomical landmarks in some fracture patterns as well as the conflicting opinions about proper orientation of the humeral component might raise intraoperative doubts about the prosthesis position. The criteria described in the literature for establishing the correct height of the humeral component in RSA rely on pectoralis major tendon insertion (approximately 5.5 cm caudad to the top of the humeral head) or on anatomical matching of the tuberositiy fragments on the diaphysis [9]. As regards version, some authors propose to implant the humeral component in neutral version [23], as described originally by Grammont, while others suggest to reproduce the anatomical retroversion [24]. In our technique, the most suitable position of the humeral component can be assessed empirically during the surgical procedure by means of an extramedullary instrument that stabilizes the trial implant to the diaphysis. Without performing any additional dissection, it is possible to evaluate shoulder stability, mobility and soft tissue tension before implanting the definitive prosthesis. Another relevant feature of this technique is the resection of the subscapularis tendon together with the lesser tuberosity. There are conflicting opinions about the role of the subscapularis on RSA stability: some authors have related the deltopectoral approach and an irreparable subscapularis to higher rates of RSA dislocation [25], while others have not found any correlation [26]. This issue has not been discussed for RSA in fractures, but in our experience, neither the deltopectoral approach nor subscapularis excision was associated with the onset of instability.
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The role of subscapularis repair on the functional outcome was not investigated in this study and should be brought into focus by randomized controlled trials. Nonetheless we suppose, in agreement with Routman [27], that subscapularis repair may have biomechanical drawbacks on RSA, especially for the potential loss of external rotation. Owing to humeral lowering in RSA, the anterior tension resulting from reconstruction of the lesser tuberosity/subscapularis can jeopardize recovery of external rotation in elderly patients, who already exhibit muscular weakness if not extensive rotator cuff tears. In all the patients of this series, the humeral component was implanted in 20° of retroversion with the intent to decrease the risk of dislocation and preserve external rotation [28]. It was our belief that this orientation was a reasonable and well-advised choice, using the deltopectoral approach and excising the subscapularis. Results on implant stability were excellent, but it is not possible to state if this was the most appropriate position for achieving the best functional outcome. RSA for proximal humeral fractures allows several variations in the surgical technique: future studies should clarify whether more satisfactory and reproducible results are more likely to be achieved by replicating a standardized implant procedure or rather by adopting different solutions on an individual basis. Conflict of interest None of the authors received payments or services, either directly or indirectly (i.e., via his or her Institution), from a third party in support of any aspect of this work. Federico A. Grassi receives consulting fees from DePuy Synthes. Ilaria Zorzolo has not received any financial payments or other benefits from any commercial entity related to the subject of this article. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). All patients provided written informed consent to enrollment in the study and to the inclusion in this article of information that could potentially lead to their identification. Human and Animal Rights The study was conducted in accordance with all institutional and national guidelines for the care and use of laboratory animals.
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