Musculoskelet Surg DOI 10.1007/s12306-014-0331-2
ORIGINAL ARTICLE
Treatment of proximal humeral fractures with reverse shoulder arthroplasty in elderly patients C. Iacobellis • A. Berizzi • C. Biz • A. Camporese
Received: 13 March 2014 / Accepted: 18 May 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of \8 mm, represent a serious and widely debated problem. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent. Hemiarthroplasty has long been used for 3- or 4-part complex fractures, even in young patients, although often with sub-optimal results, due to reabsorption of tuberosities. This complication has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical aspects are best to adopt. Materials and methods There were 33 patients in this study, mean age 76.6 years (range 54–85). Fractures were classified according to Neer. Surgery was undertaken on average 4.4 days after trauma. The deltopectoral approach was used. Sutures were hooked over the major and lesser tubercles for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS), and the ratio C. Iacobellis (&) A. Berizzi C. Biz A. Camporese Orthopaedic Clinic, University of Padua, Via Giustiniani 2, 35100 Padua, Italy e-mail: [email protected]
between healthy and operated shoulders was calculated. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot. Results Mean follow-up was 42.3 months (range 10–121). According to the CS, mean pain was 12.6/15 (range 3–15/ 15), activities of daily living 16.3/20 (range 8–20/20), ROM 21.8 (range 8–32/40) and power 5.4/25 (range 2–12/25). Total mean CS was 56.4 (range 23–80/100). The mean DASH score was 49.7 (range 32–90). The ratio of the CS parameters between opposite and operated shoulders was on average 72.8 % (range 28–90 %). Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %). Conclusions Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they do offer good stability, even in cases of damage to the rotator cuff. Reverse prostheses have great advantages as regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. In our cases, the first 3 reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures becomes more feasible. We prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. Possible scapular notching must be foreseen when inserting the glenosphere. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65. Prolonged physiokinesitherapy is essential.
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Keywords Proximal humeral fractures Reverse prosthesis Shoulder arthroplasty
4.4 days after trauma (range 1–30). Excluding case 26 (operated after 30 days), the mean falls to 3.6 days (Table 1).
Introduction
Surgical technique
Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of less than 8 mm, sometimes together with dislocation of the humeral head, represent a serious and widely debated problem as to what the best treatment is. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent, and complete recovery of the joint is rare. The literature of the last few decades is inconsistent, although recourse to surgery has recently increased [1]. However, even recently [2], therapy without surgery has been viewed as sufficient in patients over 65 in whom surgical treatment would include plating or prostheses [3, 4]. In elderly patients, especially post-menopausal women, low bone stock often hinders proper purchase of the screws, preventing early mobilization, with an increase in the percentage of failures [5, 6]. Hemiarthroplasty of the shoulder has long been used for 3- or 4-part complex fractures, even in young patients, although often with suboptimal results, due to reabsorption of tuberosities. This complication is widely reported in numerous publications with variable percentage from 11 to 46 % [7–11]. It has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities [12, 13]. Such prostheses have been increasingly used in the last 10 years, also for fractures. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. Since we have seen both excellent and poor results, we carried out a critical analysis of our patients’ records in order to assess advantages and disadvantages. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical approaches are best to adopt.
Under general anaesthesia, the patient was positioned in the beach chair position. The deltopectoral approach was used; in this way, even diaphyseal fractures due to the introduction of the stem and undislocated fractures not clearly defined in pre-operative X-rays could be treated. After the first few cases, we always positioned two Verbrugge clamps to protect the diaphyseal wall when introducing the test stems and did not have any more fractures caused by them. Once the fracture was exposed, sutures were hooked over the major and lesser tubercles, for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. A Kirschner wire was then applied slightly distally and anteriorly with respect to the centre of the articular surface of the scapular glenoid (Fig. 1), thus lowering the glenosphere slightly to avoid conflict with the lower glenoid pole (Figs. 2, 3), which may result in scapular notching. All reverse prostheses applied were from SMR LIMA with 36-mm glenospheres. The stems were conical, uncemented and finned, 80 mm long, with proximal diameters between 14 and 21 mm. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS) [15], and the ratio between healthy and operated shoulders was calculated. We believe that the ratio between the CS of both shoulders is important because, in elderly patients, scores also fall in the healthy shoulder, which becomes a substantial point of reference for the evaluation of results. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot [16] as follows: grade 0 for ‘‘no notch’’, grade 1 for ‘‘small notch’’, grade 2 for ‘‘notch with condensation’’, grade 3 for ‘‘erosion up to the inferior screw’’ and grade 4 for ‘‘erosion over the inferior screw with extension under the base plate’’.
Materials and methods Results There were 33 patients in this study (5 men, 28 women), mean age 76.6 years (range 54–85). Fractures involved the right side in 18 cases and the left in 15. Fractures were classified according to Neer [14] as follows: four parts (26 cases, of which 5 with dislocation), and three parts with metaphyseal hinge distances of \8 mm (seven cases, two with dislocation). Surgery was undertaken on average
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Mean follow-up was 42.3 months (range 10–121). According to the CS, mean pain was 12.6/15 (range 3–15/ 15), activities of daily living 16.3/20 (range 8–20/20), ROM 21.8 (range 8–32/40) and power 5.4/25 (range 2–12/ 25). Total mean CS was 56.4 (range 23–80/100). The mean DASH score was 49.7 (range 32–90). The ratio of the CS
F 80
F 79
F 84
F 81
F 54
F 78
M 76
F 78
M 67 F 81
F 80
M 70
F 78
22. SR
23. RA
24. CM
25. BM
26. PA
27. FG
28. VL
29. CP 30. TM
31. ML
32. PR
33. PS
F 80
14.VR
21. KA
F 77
13. BA
F 77
F 80
12. FO
20. LM
F 79
11. GL
F 82
M 63
10. BM
F 81
M 62
9. FA
19. IF
F 75
8. FE
18. SV
F 78
7. RM
F 81
F 75
6. BE
17. PA
F 79
5. DI
F 85
F 74 F 71
3. VA 4. FM
F 82
F 80
2. FS
16. MM
F 80
1. RI
15. SM
Gender (years)
Patients
4
4
4, D
3 4
4
4
4,D
4, D
3
3
3
3, D
4
4
4
3
4
3, D
4
4
4
4
4, D
4
4
3
4
4
4 4
4
4, D
Rx Neer Dislocation (D)
Table 1 Cases and results
diaphyseal fractures
Dislocation and revision
diaphyseal fractures
subclavian artery injury
diaphyseal fractures
Complications Intra e immediately postoperative
10
10
12
12 12
12
12
14
20
20
20
20
22
23
24
25
25
34
39
40
55
56
60
62
70
72
73
75
78
88 80
100
121
Followup (months)
36
54
45
46 50
32
90
64
54
56
50
65
74
43
72
42
56
40
51
45
40
47
50
39
46
40
38
69
43
42 37
40
45
DASH
15
12
10
15 12
15
5
10
10
14
14
15
3
8
6
15
15
15
13
12
15
14
14
15
13
11
15
15
14
12 15
13
15
Pain (0–15)
20
16
8
20 12
20
8
10
20
16
16
16
10
16
8
20
18
18
20
14
16
20
10
20
16
20
20
20
16
18 20
16
20
Activities of daily living (0–20)
30
20
10
32 16
31
8
14
24
16
16
14
8
20
18
20
16
16
26
18
30
26
22
26
26
22
26
18
30
30 30
30
30
Range of motion (0–40)
5
5
2
13 4
11
2
4
4
5
4
4
4
4
4
5
4
7
4
5
5
7
4
10
5
12
4
3
5
8 6
5
5
Power (0–25)
70
53
30
80 44
77
23
38
58
51
50
49
25
48
36
60
53
66
63
49
66
67
50
71
60
65
65
56
65
68 71
64
70
CS (0–100)
88
76
48
87 87
85
28
65
80
65
60
63
34
61
54
75
77
84
81
67
79
90
70
85
70
72
86
83
78
82 86
77
80
% CS in relation to contralateral shoulder (%)
0
0
0
0 0
0
2
2
0
0
0
1
0
2
0
0
0
0
1
0
0
1
0
0
0
0
0
0
0
1 0
0
2
Scapular notching according to Nerot
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parameters between opposite and operated shoulders was 72.8 % (range 28–90 %) on average. There were four intra-operative complications: three diaphyseal fractures (cases 9, 20, 27) treated with wires, and one subclavian arteriorrhexis in an old untreated fracture (case 17). In the latter case, the vascular surgeon applied a bypass, and immediately after, the orthopaedic surgeon inserted the reverse prosthesis. There was one post-operative complication: dislocation of the prosthesis 2 days after surgery, with instability (case 21), resolved with surgery. Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %).
Fig. 1 To prepare the glenoid seat, Kirschner guide wire is applied slightly distally and anteriorly with respect to the centre of the articular surface
Discussion One way of choosing a prosthesis for 3- or 4-part humeral fractures is by examining cases of failed plating in elderly patients [5, 6]. The risk of failure is greatest in fractures of the collum anatomicum humeri with possible damage to vascularization of the humeral head, especially in 4-part fractures. In addition, the metaphyseal hinge distance is often \8 mm; this is significant due to the possibility of interruption of the anterior circumflex artery, which we consider to be essential for vascularization of the humeral head [4, 17], although several authors assign more importance to the posterior circumflex artery [18]. In a comparative study between non-operative treatment and plate surgery, Fialestad et al. [19] did not find very different results at 1-year follow-up. Faced with very probable failure, with later painful stiffness of the operated shoulder, surgeons must decide either not to operate or to insert a prosthesis. Partial protheses may give poor results, mainly due to reabsorption of tuberosities [20, 21], a frequent complication in elderly patients reported by many authors with variable percentages: Kontakis et al. [7] 11.15 %; Mighell MA et al. [8] 20 %; Boileau P et al. [9] 23 %; Hasan et al. [10] 43 %; and Kralinger et al. [11] 46.1 % of patients. Several comparative studies of non-operative treatment versus surgery with prostheses in elderly patients have been carried out. In one such study of two groups of average age 77, Olerud et al. [23] concluded that, between non-operative treatment and surgery with a partial prosthesis, ROM being equal, operated patients had less pain later and better quality of life. In elderly patients with prostheses, Aldegheri and Iacobellis [24] found less pain and improved quality of life, but less satisfactory results in ROM. Conversely, in two groups of patients over the age of 64, Boons et al. [2] did not find significant differences between the
Fig. 2 Case 16 a, b pre-operative X ray; c, d post-operative check-up; e, f follow-up 34 months later
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Fig. 3 Case 28 a, b pre-operative X ray; c, d post-operative check-up; e, f follow-up 16 months later
two types of treatment. These controversial results have given rise to several studies on groups of patients receiving reverse prostheses for complex proximal humeral fractures. Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they offer good stability, even in cases of damage to the rotator cuff, and can work with the deltoid only. Reverse prostheses have great advantages with regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. Bufquin et al. [12] reported satisfactory functional results even in patients with reverse prostheses and resorption of tuberosities in 53 % of cases. Comparing two groups with and without resorption, Gallinet et al. [13] reported that results in the former group were not disastrous. The length of time that these prostheses can remain functional is a matter of debate. Several authors have reported cases of patients from 58 to 77 years of age, however, mostly in the 70 s [22, 24–27]. Some authors [25, 26] believe that prostheses are not completely reliable after a mean follow-up of 6.5 years. In our cases, the first three reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures will become more feasible. However, this study was subject to several limitations: its retrospective nature, the lack of a control group, the small study size limited to 33 patients, and the wide range of age, as well as the follow-up, between 10 and 121 months. Therefore, we recognize that further research is required, and a prospective study in the treatment of proximal humeral fractures with reverse arthroplasty would be desirable. As for technique, we prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. We had three humeral fractures treated with lengthening of the deltopectoral incision and then stabilized with wires.
Another point to remember is that the transdeltoid approach allows minimum damage to the circumflex nerve [28]. Possible scapular notching must be foreseen when inserting the glenosphere. This complication is reported by several authors with very variable percentages, ranging from 13 [29], 19 [30], 25 [31], 43 [32], 68 [33] to 96 [34]. The severity of scapular notching is often not reported. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Larger 36-mm glenospheres, which we used in the group of patients described above, may reduce this problem still further. We agree with several authors [12, 13] that tuberosities should be re-inserted in cases of only slightly degenerated cuffs. This results in an increase in both intra- and extra-rotation. Lastly, efficient and prolonged physiokinesitherapy is essential. The results achieved are good with regard to pain and sufficient/good with regard to range of motion and activities of daily living, considering the severity of the fractures and the age of the patients. We believe that reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65 for significant functional recovery in shoulders otherwise risking painful stiffness. Conflict of interest
None.
References 1. Min W, Davidovitch RI, Tejwani NC (2012) Three-and four-part proximal humerus fractures. Evolution to operative care. Bull NYU Hosp Jt Dis 70:25–34 2. Boons HW, Goosen JH, van Grinsven S, van Susante JL, van Loon CJ (2012) Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial. Clin Orthop Relat Res 470:3483–3491
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Musculoskelet Surg 3. Babst R, Brunner F (2007) Plating in proximal humeral fractures. Eur J Trauma Emerg Surg 4:345–356 4. Klitscher D, Blum J, Andreas D, Hessmann M, Kuechle R, Du Prel JB, Rommens PM (2008) Osteosynthesis of proximal humeral fractures with the fixed angle Philos-plate. Eur J Trauma Emerg Surg 1:29–36 5. Schliemann B, Siemoneit J, Theisen Ch, Ko¨sters C, Weimann A, Raschke MJ (2012) Complex fractures of the proximal humerus in the elderly—outcome and complications after locking plate fixation. Musculoskelet Surg 96(Suppl 1):S3–11 6. Shahid R, Mushtaq A, Northover J, Maqsood M (2008) Outcome of proximal humerus fractures treated by PHILOS plate internal fixation. Experience of a district general hospital. Acta Orthop Belg 74:602–608 7. Kontakis G, Koutras C, Tosounidis T, Giannoudis P (2008) Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br 90:1407–1413 8. Mighell MA, Kolm GP, Collinge CA, Frankel MA (2003) Outcomes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg 12:569–577 9. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole´ D (2002) Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 11:401–412 10. Hasan SS, Leith JM, Campbell B, Kapil R, Smith KL, Matsen FA 3rd (2002) Characteristics of unsatisfactory shoulder arthroplasty. J Shoulder Elbow Surg 11:431–441 11. Kralinger F, Schwaiger R, Wambacher M, Farrell E, MenthChiari W, Lajtai G, Hu¨bner C, Resch H (2004) Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multicentre study of 167 patients. J Bone Joint Surg Br 86:217–219 12. Bufquin T, Hersan A, Hubert L, Massin P (2007) Reverse shoulder arthroplasty for the treatment of three-and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br 89:516–520 13. 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 14. Neer CS (1970) Displaced proximal humeral fractures. Classification and evaluation. J Bone Joint Surg Am 52:1077–1089 15. Constant CR, Mourley AHG (1987) A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 214:160–164 16. Valenti PH, Boutens D, Nerot C, Oldroyd GED (2001) Delta 3 reversed prosthesis for osteoarthritis with massive rotator cuff tear: long term results ([ 5 years). In: Walch G, Boileau P, Mole´ D (eds) 2000 shoulder prostheses: two to ten years follow-up. Ed. Sauramps Medical, Montpellier, pp 253–259 17. Gerber C, Schneeberger AG, Vinh TS (1990) The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am 72:1486–1494 18. Hertel R, Hempfing A, Stiehler M, Leunig M (2004) Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 13:427–433 19. Fjalestad T, Hole MØ, Hovden IA, Blu¨cher J, Strømsøe K (2012) Surgical treatment with an angular stable plate for complex
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displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma 26:98–106 Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE (2003) Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am 85:1215–1223 Nijs S, Broos P (2009) Outcome of shoulder hemiarthroplasty in acute proximal humeral fractures: a frustrating meta-analysis experience. Acta Orthop Belg 75:445–451 Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L (2009) Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Rev Chir Orthop Traumatol 95:48–55 Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J (2011) Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 20:1025–1033 Aldegheri R, Iacobellis C (2009) La sostituzione protesica nelle fratture prossimali d’omero nell’anziano. G. I. O.T. 35: 6–15 Cazeneuve JF, Cristofari DJ (2009) Delta III C: radiological outcome for acute complex fractures of the proximal humerus in elderly patients. Rev Chir Orthop Traumatol 95:325–329 Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G (2006) Reverse total shoulder arthroplasty. survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 88:1742–1747 Terragnoli F, Zattoni G, Damiani L, Caprioli A, Li Bassi G (2007) Treatment of proximal humeral fractures with reverse prostheses in elderly patients. J Orthopaed Traumatol 8:71–76 Stecco C, Gagliano G, Lancerotto L, Tiengo C, Macchi V, Porzionato A, De Caro R, Aldegheri R (2010) Surgical anatomy of the axillary nerve and its implication in the transdeltoid approaches to the shoulder. J Shoulder Elbow Surg 19:1166–1174 Roche CP, Marczuk Y, Wright TW, Flurin PH, Grey S, Jones R, Routman HD, Gilot G, Zuckerman JD (2013) Scapular notching and osteophyte formation after reverse shoulder replacement: radiological analysis of implant in male and female patients. J Bone Joint Surg Br 95:530–535 Boileau P, Moineau G, Roussanne Y, O’Shea K (2011) Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res 469:2558–2567 Brorson S, Rasmussen JV, Olsen BS, Frich LH, Jensen SL, Hro´bjartsson A (2013) Reverse shoulder arthroplasty in acute fractures of the proximal humerus: a systematic review. Int J Shoulder Surg 7:70–78 Muh SJ, Streit JJ, Wanner JP, Lenarz CJ, Shishani Y, Rowland DY, Riley C, Nowinski RJ, Edwards TB, Gobezie R (2013) Early follow-up of reverse total shoulder arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am 95:1877–1883 Le´vigne C, Garret J, Boileau P, Alami G, Favard L, Walch G (2011) Scapular notching in reverse shoulder arthroplasty: is it important to avoid it and how? Clin Orthop Relat Res 469:2512–2520 Nicholson GP, Strauss EJ, Sherman SL (2011) Scapular notching: recognition and strategies to minimize clinical impact. Clin Orthop Relat Res 469:2521–2530
ORIGINAL ARTICLE
Treatment of proximal humeral fractures with reverse shoulder arthroplasty in elderly patients C. Iacobellis • A. Berizzi • C. Biz • A. Camporese
Received: 13 March 2014 / Accepted: 18 May 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Background Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of \8 mm, represent a serious and widely debated problem. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent. Hemiarthroplasty has long been used for 3- or 4-part complex fractures, even in young patients, although often with sub-optimal results, due to reabsorption of tuberosities. This complication has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical aspects are best to adopt. Materials and methods There were 33 patients in this study, mean age 76.6 years (range 54–85). Fractures were classified according to Neer. Surgery was undertaken on average 4.4 days after trauma. The deltopectoral approach was used. Sutures were hooked over the major and lesser tubercles for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS), and the ratio C. Iacobellis (&) A. Berizzi C. Biz A. Camporese Orthopaedic Clinic, University of Padua, Via Giustiniani 2, 35100 Padua, Italy e-mail: [email protected]
between healthy and operated shoulders was calculated. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot. Results Mean follow-up was 42.3 months (range 10–121). According to the CS, mean pain was 12.6/15 (range 3–15/ 15), activities of daily living 16.3/20 (range 8–20/20), ROM 21.8 (range 8–32/40) and power 5.4/25 (range 2–12/25). Total mean CS was 56.4 (range 23–80/100). The mean DASH score was 49.7 (range 32–90). The ratio of the CS parameters between opposite and operated shoulders was on average 72.8 % (range 28–90 %). Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %). Conclusions Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they do offer good stability, even in cases of damage to the rotator cuff. Reverse prostheses have great advantages as regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. In our cases, the first 3 reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures becomes more feasible. We prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. Possible scapular notching must be foreseen when inserting the glenosphere. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65. Prolonged physiokinesitherapy is essential.
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Keywords Proximal humeral fractures Reverse prosthesis Shoulder arthroplasty
4.4 days after trauma (range 1–30). Excluding case 26 (operated after 30 days), the mean falls to 3.6 days (Table 1).
Introduction
Surgical technique
Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of less than 8 mm, sometimes together with dislocation of the humeral head, represent a serious and widely debated problem as to what the best treatment is. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent, and complete recovery of the joint is rare. The literature of the last few decades is inconsistent, although recourse to surgery has recently increased [1]. However, even recently [2], therapy without surgery has been viewed as sufficient in patients over 65 in whom surgical treatment would include plating or prostheses [3, 4]. In elderly patients, especially post-menopausal women, low bone stock often hinders proper purchase of the screws, preventing early mobilization, with an increase in the percentage of failures [5, 6]. Hemiarthroplasty of the shoulder has long been used for 3- or 4-part complex fractures, even in young patients, although often with suboptimal results, due to reabsorption of tuberosities. This complication is widely reported in numerous publications with variable percentage from 11 to 46 % [7–11]. It has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities [12, 13]. Such prostheses have been increasingly used in the last 10 years, also for fractures. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. Since we have seen both excellent and poor results, we carried out a critical analysis of our patients’ records in order to assess advantages and disadvantages. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical approaches are best to adopt.
Under general anaesthesia, the patient was positioned in the beach chair position. The deltopectoral approach was used; in this way, even diaphyseal fractures due to the introduction of the stem and undislocated fractures not clearly defined in pre-operative X-rays could be treated. After the first few cases, we always positioned two Verbrugge clamps to protect the diaphyseal wall when introducing the test stems and did not have any more fractures caused by them. Once the fracture was exposed, sutures were hooked over the major and lesser tubercles, for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. A Kirschner wire was then applied slightly distally and anteriorly with respect to the centre of the articular surface of the scapular glenoid (Fig. 1), thus lowering the glenosphere slightly to avoid conflict with the lower glenoid pole (Figs. 2, 3), which may result in scapular notching. All reverse prostheses applied were from SMR LIMA with 36-mm glenospheres. The stems were conical, uncemented and finned, 80 mm long, with proximal diameters between 14 and 21 mm. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS) [15], and the ratio between healthy and operated shoulders was calculated. We believe that the ratio between the CS of both shoulders is important because, in elderly patients, scores also fall in the healthy shoulder, which becomes a substantial point of reference for the evaluation of results. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot [16] as follows: grade 0 for ‘‘no notch’’, grade 1 for ‘‘small notch’’, grade 2 for ‘‘notch with condensation’’, grade 3 for ‘‘erosion up to the inferior screw’’ and grade 4 for ‘‘erosion over the inferior screw with extension under the base plate’’.
Materials and methods Results There were 33 patients in this study (5 men, 28 women), mean age 76.6 years (range 54–85). Fractures involved the right side in 18 cases and the left in 15. Fractures were classified according to Neer [14] as follows: four parts (26 cases, of which 5 with dislocation), and three parts with metaphyseal hinge distances of \8 mm (seven cases, two with dislocation). Surgery was undertaken on average
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Mean follow-up was 42.3 months (range 10–121). According to the CS, mean pain was 12.6/15 (range 3–15/ 15), activities of daily living 16.3/20 (range 8–20/20), ROM 21.8 (range 8–32/40) and power 5.4/25 (range 2–12/ 25). Total mean CS was 56.4 (range 23–80/100). The mean DASH score was 49.7 (range 32–90). The ratio of the CS
F 80
F 79
F 84
F 81
F 54
F 78
M 76
F 78
M 67 F 81
F 80
M 70
F 78
22. SR
23. RA
24. CM
25. BM
26. PA
27. FG
28. VL
29. CP 30. TM
31. ML
32. PR
33. PS
F 80
14.VR
21. KA
F 77
13. BA
F 77
F 80
12. FO
20. LM
F 79
11. GL
F 82
M 63
10. BM
F 81
M 62
9. FA
19. IF
F 75
8. FE
18. SV
F 78
7. RM
F 81
F 75
6. BE
17. PA
F 79
5. DI
F 85
F 74 F 71
3. VA 4. FM
F 82
F 80
2. FS
16. MM
F 80
1. RI
15. SM
Gender (years)
Patients
4
4
4, D
3 4
4
4
4,D
4, D
3
3
3
3, D
4
4
4
3
4
3, D
4
4
4
4
4, D
4
4
3
4
4
4 4
4
4, D
Rx Neer Dislocation (D)
Table 1 Cases and results
diaphyseal fractures
Dislocation and revision
diaphyseal fractures
subclavian artery injury
diaphyseal fractures
Complications Intra e immediately postoperative
10
10
12
12 12
12
12
14
20
20
20
20
22
23
24
25
25
34
39
40
55
56
60
62
70
72
73
75
78
88 80
100
121
Followup (months)
36
54
45
46 50
32
90
64
54
56
50
65
74
43
72
42
56
40
51
45
40
47
50
39
46
40
38
69
43
42 37
40
45
DASH
15
12
10
15 12
15
5
10
10
14
14
15
3
8
6
15
15
15
13
12
15
14
14
15
13
11
15
15
14
12 15
13
15
Pain (0–15)
20
16
8
20 12
20
8
10
20
16
16
16
10
16
8
20
18
18
20
14
16
20
10
20
16
20
20
20
16
18 20
16
20
Activities of daily living (0–20)
30
20
10
32 16
31
8
14
24
16
16
14
8
20
18
20
16
16
26
18
30
26
22
26
26
22
26
18
30
30 30
30
30
Range of motion (0–40)
5
5
2
13 4
11
2
4
4
5
4
4
4
4
4
5
4
7
4
5
5
7
4
10
5
12
4
3
5
8 6
5
5
Power (0–25)
70
53
30
80 44
77
23
38
58
51
50
49
25
48
36
60
53
66
63
49
66
67
50
71
60
65
65
56
65
68 71
64
70
CS (0–100)
88
76
48
87 87
85
28
65
80
65
60
63
34
61
54
75
77
84
81
67
79
90
70
85
70
72
86
83
78
82 86
77
80
% CS in relation to contralateral shoulder (%)
0
0
0
0 0
0
2
2
0
0
0
1
0
2
0
0
0
0
1
0
0
1
0
0
0
0
0
0
0
1 0
0
2
Scapular notching according to Nerot
Musculoskelet Surg
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Musculoskelet Surg
parameters between opposite and operated shoulders was 72.8 % (range 28–90 %) on average. There were four intra-operative complications: three diaphyseal fractures (cases 9, 20, 27) treated with wires, and one subclavian arteriorrhexis in an old untreated fracture (case 17). In the latter case, the vascular surgeon applied a bypass, and immediately after, the orthopaedic surgeon inserted the reverse prosthesis. There was one post-operative complication: dislocation of the prosthesis 2 days after surgery, with instability (case 21), resolved with surgery. Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %).
Fig. 1 To prepare the glenoid seat, Kirschner guide wire is applied slightly distally and anteriorly with respect to the centre of the articular surface
Discussion One way of choosing a prosthesis for 3- or 4-part humeral fractures is by examining cases of failed plating in elderly patients [5, 6]. The risk of failure is greatest in fractures of the collum anatomicum humeri with possible damage to vascularization of the humeral head, especially in 4-part fractures. In addition, the metaphyseal hinge distance is often \8 mm; this is significant due to the possibility of interruption of the anterior circumflex artery, which we consider to be essential for vascularization of the humeral head [4, 17], although several authors assign more importance to the posterior circumflex artery [18]. In a comparative study between non-operative treatment and plate surgery, Fialestad et al. [19] did not find very different results at 1-year follow-up. Faced with very probable failure, with later painful stiffness of the operated shoulder, surgeons must decide either not to operate or to insert a prosthesis. Partial protheses may give poor results, mainly due to reabsorption of tuberosities [20, 21], a frequent complication in elderly patients reported by many authors with variable percentages: Kontakis et al. [7] 11.15 %; Mighell MA et al. [8] 20 %; Boileau P et al. [9] 23 %; Hasan et al. [10] 43 %; and Kralinger et al. [11] 46.1 % of patients. Several comparative studies of non-operative treatment versus surgery with prostheses in elderly patients have been carried out. In one such study of two groups of average age 77, Olerud et al. [23] concluded that, between non-operative treatment and surgery with a partial prosthesis, ROM being equal, operated patients had less pain later and better quality of life. In elderly patients with prostheses, Aldegheri and Iacobellis [24] found less pain and improved quality of life, but less satisfactory results in ROM. Conversely, in two groups of patients over the age of 64, Boons et al. [2] did not find significant differences between the
Fig. 2 Case 16 a, b pre-operative X ray; c, d post-operative check-up; e, f follow-up 34 months later
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Musculoskelet Surg
Fig. 3 Case 28 a, b pre-operative X ray; c, d post-operative check-up; e, f follow-up 16 months later
two types of treatment. These controversial results have given rise to several studies on groups of patients receiving reverse prostheses for complex proximal humeral fractures. Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they offer good stability, even in cases of damage to the rotator cuff, and can work with the deltoid only. Reverse prostheses have great advantages with regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. Bufquin et al. [12] reported satisfactory functional results even in patients with reverse prostheses and resorption of tuberosities in 53 % of cases. Comparing two groups with and without resorption, Gallinet et al. [13] reported that results in the former group were not disastrous. The length of time that these prostheses can remain functional is a matter of debate. Several authors have reported cases of patients from 58 to 77 years of age, however, mostly in the 70 s [22, 24–27]. Some authors [25, 26] believe that prostheses are not completely reliable after a mean follow-up of 6.5 years. In our cases, the first three reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures will become more feasible. However, this study was subject to several limitations: its retrospective nature, the lack of a control group, the small study size limited to 33 patients, and the wide range of age, as well as the follow-up, between 10 and 121 months. Therefore, we recognize that further research is required, and a prospective study in the treatment of proximal humeral fractures with reverse arthroplasty would be desirable. As for technique, we prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. We had three humeral fractures treated with lengthening of the deltopectoral incision and then stabilized with wires.
Another point to remember is that the transdeltoid approach allows minimum damage to the circumflex nerve [28]. Possible scapular notching must be foreseen when inserting the glenosphere. This complication is reported by several authors with very variable percentages, ranging from 13 [29], 19 [30], 25 [31], 43 [32], 68 [33] to 96 [34]. The severity of scapular notching is often not reported. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Larger 36-mm glenospheres, which we used in the group of patients described above, may reduce this problem still further. We agree with several authors [12, 13] that tuberosities should be re-inserted in cases of only slightly degenerated cuffs. This results in an increase in both intra- and extra-rotation. Lastly, efficient and prolonged physiokinesitherapy is essential. The results achieved are good with regard to pain and sufficient/good with regard to range of motion and activities of daily living, considering the severity of the fractures and the age of the patients. We believe that reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65 for significant functional recovery in shoulders otherwise risking painful stiffness. Conflict of interest
None.
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