Shoulder Hemiarthroplasty in Proximal Humerus Fractures

Abstract

We present a review of the most recent published articles related to shoulder hemiarthroplasty in proximal humerus fractures. Four-part proximal humerus fractures represent between 2% and 10% of all proximal fractures where displacement occurs as a result of the muscular deforming force. Hemiarthroplasty is indicated in patients with four-part fractures and in elderly patients with osteoporotic bone who have fracture-dislocations. In both groups of patients, obtaining a secure stable reduction using internal fixation techniques is difficult, and the rate of osteonecrosis can range from 13% to 35% in four-part fractures. Hemiarthroplasty can also be considered in patients with three-part fractures and fracture-dislocations when bone quality is poor and the degree of conminution precludes satisfactory reduction and internal fixation. Headsplitting proximal humerus fractures in elderly patients also should be treated with hemiarhroplasty. Primary replacement can be considered in younger patients with four-part proximal fractures if acceptable redution cannot be obtained. The important surgical principles when performing a hemiartroplasty for four-part proximal humeral fractures include the following: the use of a deltopectoral approach, allowing preservation of the deltoid origin and insertion; restoration of humeral length and retroversion; and secure fixation of the tuberosities to the prosthesis, to the shaft and to one another. Results of hemiarthroplasty for four-part proximal humerus fractures are somewhat difficult to interpret, specifically because other proximal humerus fracture patterns often are included in published series. Wide variation in outcomes measurements also makes comparisons between studies difficult. Despite these limitations, hemiarthroplasty offers reliable pain relief and reasonable levels of patient satisfaction, but only modest functional results. Limited use with activities of daily living below shoulder level may be reliably obtained but overhead use is not typical following this surgery. Significant residual pain generally tends to be associated with moderate activity: minimal pain occurs at rest. Even when motion and functional results are limited, pain relief is reported to be consistent.