Primary Arthroplasty for Proximal Humeral Fractures and Fracture Sequelae Following Implant Failure

Abstract

Proximal humeral fractures and fracture-dislocations, which are not amenable to predictable anatomical fixation, pose several treatment challenges, especially in elderly individuals. Malunion of the fracture fragments can be an outcome, while humeral head avascular necrosis and fracture nonunion can complicate an attempted internal fixation leading to articular surface degradation and secondary osteoarthritis. These patients often present with painful, stiff shoulders secondary to a distorted proximal humerus, scarred deltoid, rotator cuff tears, and/or atrophied rotator cuff muscles. The anatomical sequelae noted from failed initial treatment makes shoulder arthroplasty more challenging, often with less predictable results and a higher risk of complications.Primary hemiarthroplasty of the shoulder is indicated for treating elderly, osteoporotic proximal humeral fractures which are often complicated by comminution, which are of three and more parts, and sometimes associated with head splitting and fracture-dislocations. The important factors influencing the outcomes include restoration of native humeral height and version with healing of the tuberosities in an acceptable position. Tuberosity malunion and nonunion equate to poor function. Hemiarthroplasty for neglected proximal humeral fractures and for revising failed internal fixation is known to fare worse compared to those performed in primary osteoarthritis and acute fractures. In current practice, fractures with distorted proximal humeral architecture, poor bone stock, and associated cuff pathology, the reverse shoulder arthroplasty is a reliable treatment option, backed by increasingly positive short and mid-term follow-up data.KeywordsPrimaryHemiTotalReverse shoulderArthroplastyProximalHumeralFracturesSequelae and implant failure