Hemiarthroplasty For Proximal Humerus Fractures Research Articles

Arthroscopic Management of Arthrofibrosis After Hemiarthroplasty for Proximal Humerus Fracture Dislocation

Poor functional outcomes after hemiarthroplasty for proximal humerus fractures are common, yet revision surgery is relatively rare. Arthroscopic treatment for postoperative stiffness can be considered in the setting of functional limits to glenohumeral range of motion impacting activities of daily living after adequate conservative treatment with physical therapy and in the setting of healed, well-positioned tuberosities and humeral components. This Technical Note illustrates a stepwise approach to an arthroscopic lysis of adhesions and capsular release for the treatment of arthrofibrosis of the shoulder. The advantages of this technique include an alternative approach to entering the glenohumeral joint under direct subacromial visualization and a 2-posterior portal approach to the inferior and anteroinferior capsule, which can be challenging to achieve in the setting of severe postsurgical arthrofibrosis.

Hemiarthroplasty for proximal humerus fractures: clinical and radiographic outcomes after an average of 19 years

BackgroundThe main objective of this retrospective analysis was to report on the long-term clinical and radiographic outcomes (>10 years) in a series of patients who have previously undergone hemiarthroplasty for proximal humerus fracture. Materials and methodsThe charts of 11 patients (12 shoulders) who underwent hemiarthroplasty for proximal humerus fractures were retrospectively analyzed and stratified based on tuberosity healed (TH) or tuberosity resorption (TR). The primary end points included range of motion measurements and patient-reported outcome scores. We obtained forward elevation, exterx nal rotation, internal rotation, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and Visual Analog Scale (VAS) scores. Tuberosity healing or resorption, acromiohumeral interval, subluxation, and humeral radiolucency were analyzed separately by 2 fellowship-trained orthopedic surgeons. ResultsThe mean age at surgery for TH patients was 60.0 ± 9.8 years and for TR patients was 57.7 ± 4.3 years. There were 7 cases in tuberosity healing cohort and 5 cases in the tuberosity resorption cohort. Implant survivorship at final follow-up was 100% (7/7) for TH and 60% (3/5) for TR; 2 patients who failed hemiarthroplasty were converted to reverse total shoulder arthroplasty. Mean postoperative forward elevation (TH: 155°, TR: 36°; P value < .01), external rotation (TH: 59°, TR: 28°; P value < .01), and internal rotation (TH:T12, TR:L3; P value = .08) were higher in the TH cohort. American Shoulder and Elbow Surgeons scores (TH: 90, TR: 40; P value < .01) and Simple Shoulder Test scores (TH: 9, TR: 2; P value < .01) were statistically significant between the 2 cohorts while VAS scores approached significance (mean VAS [TH: 1, TR: 4; P value = .08]). DiscussionTo our knowledge, this study provides the longest follow-up to date for outcomes following hemiarthroplasty with fracture. Significant improvements in shoulder function and reduction in pain levels are sustainable even after 19 years in patients whose tuberosity heals. Hemiarthroplasty remains a viable option for younger candidates whose tuberosity will heal postoperatively.

Trends in the treatment of proximal humerus fractures in the United States Medicare population

BackgroundMany factors influence the decision-making in the treatment of proximal humerus fractures. With the increasing popularity of reverse shoulder arthroplasty (RSA), treatment strategies for proximal humerus fractures are evolving. The extent to which expanding indications for RSA has impacted the way surgeons treat these fractures is still under question. The purpose of the current study was to determine trends in the treatment of proximal humerus fractures in the United States Medicare population from 2010 to 2019. Materials and methodsThe Mariner subset of the PearlDiver database, a Health Insurance Portability and Accountability Act compliant national insurance database, was queried for Medicare patients who sustained a proximal humerus fracture from 2010 to 2019. Current Procedural Terminology and International Classification of Diseases codes were used to determine which patients were treated nonoperatively vs. operatively in the acute setting. Operative interventions included RSA, hemiarthroplasty, or open reduction internal fixation (ORIF). Poisson regression was used to detect the prevalence trends. Chi-square test was used to detect differences in operative treatment between 2010 and 2019. Descriptive statistics were calculated. Statistical significance was set at <0.05. ResultsIn the Medicare population queried, the prevalence of operative management of proximal humerus fractures remained largely unchanged (6.5% of all fractures treated operatively in 2010, compared to 6.3% of all fractures treated operatively in 2019; P = .64). The utilization of RSA for proximal humerus fractures increased substantially during the last decade (8.9% of operations in 2010, compared to 50.9% of operations in 2019; P ≤ .001). The utilization of hemiarthroplasty has continuously decreased (24.6% of operations in 2010, compared to 5.2% of operations in 2019; P ≤ .001). The utilization of ORIF for these fractures has also decreased during the last decade (69.2% of operations in 2010, compared to 47.7% of operations in 2019; P ≤ .001). ConclusionIn the Medicare population, there was no difference in the proportion of proximal humerus fractures treated operatively over the decade. The use of ORIF and hemiarthroplasty for proximal humerus fractures has declined significantly. More surgeons are utilizing RSA as a treatment for proximal humerus fractures in this patient population.

Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae. Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk. The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P=.102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P=.004), lower rate of previous procedure (4.3% vs. 51.9%; P<.001), lower bone graft use (28.6% vs. 59.6%; P<.001), and a longer length of stay (5.9 vs. 3.0 days; P<.001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P=.523), forward elevation (98° vs. 93°; P=.627), external rotation (30° vs. 23°; P=.215), internal rotation score (4.0 vs. 4.5; P=.589), satisfaction (P=.592), ASES scores (64.4 vs. 57.1; P=.168), complications (27.1% vs. 28.8%; P=.836), or reoperations (11.4% vs. 19.2%; P=.229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P=.172), with 15-year reoperation rates of 13.7% and 24%, respectively (P=.098). HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review.

Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA. An electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA). Fifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, p = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, p = 0.026). RSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.

Primary stemmed shoulder hemiarthroplasty for proximal humerus fractures in active patients aged ≤40 years: average 20 years of follow-up

BackgroundAlthough open reduction and internal fixation is a standard treatment for the management of severe proximal humeral fractures, it is associated with high risk for humeral head necrosis. Therefore, stemmed hemiarthroplasty (SHA) may be successfully used for older patients, but the expected long-term outcomes for young, active patients remain unclear. Therefore, in this study, we report the long-term clinical outcomes of SHA of the shoulder in young, active patients aged <40 years. MethodsBetween 1986 and 2003, we investigated 11 shoulders of 11 patients (all male) for primary SHA of the shoulder. Five patients received cemented hemiarthroplasty. The average age was 28.6 years (range, 17–40 years), and the average follow-up was 20.5 years (range, 18–26 years). Fractures were 2-part (dislocation of anatomical neck fracture) in 3 patients, 3-part in 2 patients, and 4-part in 6 patients. Clinical function was assessed using the Japanese Orthopaedic Association score and Constant score. Acromiohumeral interval, prosthetic loosening, superior migration, and glenoid erosion were compared between the immediate postoperative and 5-year, 10-year, and most recent (final) follow-up radiographs. ResultsThe mean Japanese Orthopaedic Association and Constant scores at final follow-up were 87.5 ± 10.6 points (range, 58–100) and 82.8 ± 12.7 points (range, 48–95), respectively. There was no change in clinical score at the final follow-up compared with scores at 5 or 10 years after surgery. Clinical outcome was poor in 1 patient (absorption of greater tuberosity) regarding range of motion. No patient had prosthetic loosening or periprosthetic fracture. Three patients had mild or moderate glenoid erosion. The acromiohumeral interval gradually decreased with time. ConclusionThere was good long-term survival of primary SHA (average, 20.2 years). No long-term concerns were identified in terms of implant loosening or severe osteoarthritis of the glenoid, despite the young age of the patients at implant (<40 years). However, poor clinical results were found in older patients with regard to absorption and malunion of the greater tuberosity. In addition, there remain substantial concerns regarding progressive glenoid erosion and the outcomes of revision to a more standard arthroplasty.

Fracture-Specific and Conventional Stem Designs in Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures-A Retrospective, Observational Study.

Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.

Risk Factors for Mortality and Readmission After Shoulder Hemiarthroplasty for Fracture.

BackgroundLimited information exists regarding mortality and readmission following proximal humerus fracture. This study examines risk factors following hemiarthroplasty for these fractures.MethodsA retrospective analysis of prospectively collected data on 788 patients treated with hemiarthroplasty for acute proximal humerus fracture from January 2005 to December 2011 was conducted. One-year mortality and 30- and 90-day hospital readmission were evaluated. Patient risk factors included age, race, gender, diabetes, American Society of Anesthesiologists (ASA) score, and body mass index.ResultsOne-year mortality rate was 5.2%. Patients with ASA ≥3 had 2.37 times (95% confidence interval [CI]: 1.05–5.32) greater mortality risk versus patients with ASA1/2. The 30-day readmission rate was 8.4% and at 90 days was 12.6%. Females had 0.53 risk of readmission versus males (95% CI: 0.29–0.96). Patients with ASA ≥3 had 1.79 (95% CI: 1.04–3.09) risk of 90-day readmission versus patients with ASA1/2; females had 0.52 (95% CI: 0.31–0.85) risk of readmission versus males. Increased age increased all odds ratios.ConclusionsReadmission rate after hemiarthroplasty for proximal humerus fracture is significant both at 30 and 90 days and is higher in males. Age and ASA ≥3 correlate with this. Diabetes and obesity were not significant risk factors for readmission or mortality.

Hemiarthroplasty for proximal humerus fractures with conservation of the whole humeral head as autograft: does it improve greater tuberosity healing?

Hemiarthroplasty (HA) for proximal humerus fracture (PHF) is associated with tuberosity complications like migration, non-union, and resorption. In order to improve the rate of consolidation of the greater tuberosity (GT), we have developed a hollow humeral head prosthesis in which the whole humeral head is inserted and used as autograft. This study is designed to evaluate the consolidation rate of the GT with this device. Twenty-two patients at mean age of 68 were treated between 2015 and 2017 for four-part fractures, fracture-dislocations, and head-split fractures with HA including the bony humeral head. The humeral prosthesis device comprises a prosthetic cephalic cup in which the detached humeral head is inserted and a cementless adjustable humeral stem which works like a jack. Mean follow-up was 14months. The consolidation of GT was followed on X-rays. As comparison, 15 published series were selected and analyzed. There were two mechanical complications related to GT consolidation (9.1%). In the 20 other cases, the GT was radiologically consolidated without displacement. While the raw proportion of complications observed in the present series was lower than that reported in each of the 15 comparative series, the proportion of complications observed in the present series was significantly different from that observed only in seven out of the 15 previous series. Whole conservation of the humeral head as an autograft along with proper surgical technique yielded in 20 consolidations of GT without displacement in 22 cases of PHF treated with hemiarthroplasty.

Is the pectoralis major tendon a reliable reference for restoration of humeral length with fracture hemiarthroplasty?

The primary objective was to calculate and to apply the numeric value of the distance from the pectoralis major tendon insertion to the superior aspect of the humeral head (PMTD) without any radiation exposure or equipment through basic data such as age, sex, height, and weight of Asian populations. We analyzed shoulder magnetic resonance images of 260 patients (107 men and 153 women; average age, 59.8 years). The superior border of the pectoralis major was identified on the transverse section and cross-referenced with the coronal section. Measurements were made inferiorly from the corresponding transverse section to the top of the humeral head superiorly in coronal view. Correlation analysis was performed between variables including the patient's age, sex, height, weight, and body mass index and the PMTD by multiple linear regression analysis. The mean PMTD was 52 mm, with an average of 55 mm for men and 49 mm for women. Sex and height were significantly correlated with PMTD. The PMTD increased to a consistent level proportionally to height, and the difference in PMTD between men and women was 3.45 mm. An equation to estimate PMTD using these findings is as follows: PMTD (in mm) = 23 + (height [cm] × 0.17) + 3.45 (the last number is added for men). This equation had a prediction error of 0.3 mm. Our study demonstrated that PMTD is a useful and reliable reference for optimal humeral height during hemiarthroplasty for proximal humerus fractures in Asian populations.

Cost Drivers After Surgical Management of Proximal Humerus Fractures in Medicare Patients.

This comparative effectiveness study sought to determine the impact of complications, readmission, and procedure choice on in-hospital and total 90-day costs for surgical management of proximal humerus fractures. Medicare claims data from the Upstate New York area (2008-2009) were evaluated. The study included all patients treated with open reduction and internal fixation (ORIF) or hemiarthroplasty for proximal humerus fracture identified by ICD-9 codes. The primary end points included in-hospital costs and total health care costs within 90 days after the index operation. Multivariable generalized linear models with negative binomial distributions and log link function were used for cost analysis. ORIF was performed in 52 cases and hemiarthroplasty in 57 cases, total n = 109. On univariate analysis, readmission increased in-hospital cost by $54,345 and total 90-day costs by $63,104, whereas complications increased in-hospital cost by $23,300 and total 90-day costs by $30,237. On multivariable analysis, ORIF was associated with 29% lower in-hospital cost compared with hemiarthroplasty [Odds Ratio 0.71; 95% Confidence Interval (CI), 0.54-0.92; P = 0.01], and readmission was associated with a 5.68-fold in-hospital cost increase (Odds Ratio 5.68; CI, 3.57-9.03; P < 0.0001). Complications and hospital readmission continue to drive cost upward underscoring the need for best practice. The acute inpatient period costs may be decreased with ORIF in appropriately selected patients with proximal humerus fractures in comparison with hemiarthroplasty. This study provides real world cost estimates with the cost implications of complications, readmissions, and procedure choice. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hemiarthroplasty for proximal humerus fracture and consequences of a comminuted greater tubercle fragment.

A prerequisite for a satisfying functional result in the treatment of comminuted fractures of the proximal humerus with hemiarthroplasty is anatomical reduction, fixation and healing of the tuberculi around the prosthetic neck in order to restore normal function of the rotator cuff. This was a retrospective study to examine the outcome after hemiarthroplasty using a prosthetic stem designed to optimise re-attachment and healing of the tuberculi (Aequalis; Tornier and Global Fx, DePuy). A special emphasis was on the effect on outcome a comminuted greater tubercle might have. At follow-up, clinical results were evaluated using the Constant score and WOOS index. All patients had radiographs taken of the injured shoulder. Quality of tubercle healing and prosthetic height were estimated; acromiohumeral distance was registered as well as greater tubercle comminution and resorption. Thirty-four patients with 35 hemiarthroplasties were included. Mean age was 71 years (range 47-88) at the time of injury. At follow-up (mean 38 months, range 23-67), the mean Constant score was 44 points (range 18-87). The mean WOOS index was 58 (range 15-96). A comminuted tubercle was associated with tubercle resorption and superior migration of the arthroplasty. Also, there was a correlation for the functional Constant score, but for the WOOS index, there was none. Like several other studies, we generally saw a group of patients with limited pain but poor range of movement in the shoulder. Our hypothesis was that comminution of the greater tubercle would correlate with both rotator cuff arthropathic radiographical features and more detrimental functional scores than average. Thus, a subtype of fracture could be identified at the time of injury and perhaps be allocated to a different treatment than hemiarthroplasty. Due to a limited number of patients in this study, we are unable to make any strong statistically supported conclusions regarding this hypothesis. Level 4 evidence.

Outcomes After Hemiarthroplasty for Proximal Humerus Fracture Are Significantly Affected by Hand Dominance.

Hand dominance has been reported to be an important factor affecting outcomes after upper extremity trauma but remains unstudied after hemiarthroplasty for fracture. This study determined whether dominance affected outcomes after hemiarthroplasty for proximal humerus fractures. Retrospective cohort study. Tertiary care referral center. Sixty-one patients, after hemiarthroplasty for proximal humerus fracture, returned for comprehensive assessment and were divided into 2 groups: dominant (DOM) shoulder affected (n = 25) and non-dominant (non-DOM) shoulder affected (n = 36). Fracture-specific proximal humeral hemiarthroplasty for displaced proximal humerus fractures. Patients were assessed with self-reported outcomes (visual analog scale pain, American Shoulder and Elbow Surgeons shoulder score, disability of the arm, shoulder, and hand questionnaire, simple shoulder test, and short form 12) and objective (range-of-motion and hand-held dynamometer strength) testing. At 49 months of mean follow-up, there were no significant differences between groups for gender, age, follow-up time, or visual analog scale pain (P > 0.256). The DOM-affected group had significantly worse scores for American Shoulder and Elbow Surgeons shoulder score (P = 0.043), disability of the arm, shoulder, and hand questionnaire (P = 0.039), and simple shoulder test (P = 0.021). The DOM-affected group also had consistently higher correlations between self-reported and objective outcomes than the non-DOM group. Patients who underwent hemiarthroplasty for fracture on their DOM shoulders had significantly poorer outcomes than patients with non-DOM-sided injuries. Although positive outcomes can be expected after hemiarthroplasty, patients should be instructed that they may have less satisfactory function and strength if their injury was on the DOM side. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The outcome of hemiarthroplasty for proximal humeral fractures is dependent on the status of the rotator cuff.

The purpose of this study was to evaluate clinical and radiological outcomes of hemiarthroplasty for proximal humerus fractures. Thirty-five patients (33 women and two men), average age at the time of surgery of 75.1 (range, 64-92) years, who underwent hemiarthroplasty for proximal humerus fracture or fracture-dislocation of the shoulder were enrolled in this study. The Constant score was used for clinical evaluation of outcomes, and X-rays were performed after a minimum follow-up period of 12 months postoperatively. Parameters for radiological evaluation were as follows: value of acromiohumeral interval (AHI), humeral offset, medial and lateral projection, and the existence of subacromial spur, a radiolucent zone around humeral stem and an osteolytic change of the greater tuberosity. The average follow-up after surgery was 45.8 (range, 13-114) months. The average postoperative Constant score was 76.2 (range, 53-96) points. The mean values of AHI and humeral offset were 8.4 and 28.3 mm, respectively. A subacromial spur was observed in ten patients, and an osteolytic change of the greater tuberosity in seven patients. There was a significant correlation between Constant score and values of AHI or humeral offset. The Constant score in patients with a subacromial spur or radiolucent zone around humeral stem was markedly lower than that in patients without them. The clinical outcome of hemiarthroplasty was influenced by factors reflecting function and conditions of the rotator cuff. Anatomical reconstruction and bone union of the tuberosities need to ensure clinical success in hemiarthroplasty.

Evidence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon

BackgroundThe primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology. MethodsWe investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells. ResultsA strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions. ConclusionOur results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.

Total shoulder arthroplasty.

Shoulder arthroplasty has been the subject of marked advances over the last few years. Modern implants provide a wide range of options, including resurfacing of the humeral head, anatomic hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty and trauma-specific implants for fractures and nonunions. Most humeral components achieve successful long-term fixation without bone cement. Cemented all-polyethylene glenoid components remain the standard for anatomic total shoulder arthroplasty. The results of shoulder arthroplasty vary depending on the underlying diagnosis, the condition of the soft-tissues, and the type of reconstruction. Total shoulder arthroplasty seems to provide the best outcome for patients with osteoarthritis and inflammatory arthropathy. The outcome of hemiarthroplasty for proximal humerus fractures is somewhat unpredictable, though it seems to have improved with the use of fracture-specific designs, more attention to tuberosity repair, and the selective use of reverse arthroplasty, as well as a shift in indications towards internal fixation. Reverse shoulder arthroplasty has become extremely popular for patients with cuff-tear arthropathy, and its indications have been expanded to the field of revision surgery. Overall, shoulder arthroplasty is a very successful procedure with predictable pain relief and substantial improvements in motion and function.

RETRACTED: Hemiarthroplasty for Proximal Humerus Fractures: Early and Late

Hemiarthroplasty has been the preferred surgical procedure for 3and 4-part proximal humeral fractures. Our retrospective study examined function and radiographic outcomes at 2and 5-year follow-up in patients who received a hemiarthroplasty for 3and 4-part proximal humeral fractures. Forty-seven consecutive patients of a single surgeon treated with a shoulder hemiarthroplasty between 2000 and 2006 were examined. Postoperative radiographs were compared with radiographs at 2 and 5 years along with active range of motion and functional outcomes scores. The mean acromiohumeral distance decreased from 10.3 mm postoperatively to 8.5 mm at 2 years and 6.7 mm at 5 years (P < 0.001). More patients had stem osteolysis and tuberosity reabsorption at 2 and 5 years compared with postoperatively (P 0.16 and P < 0.001, respectively). Multiple measures of functional outcome were obtained and all found to be worse at 5 years than at 2 years. Pain scores increased from 2 to 5-year follow-up (P 0.018). Hemiarthropasty has a high rate of long-term complications, including decreased acromiohumeral distance, stem osteolysis, and tuberosity reabsorption. Pain scores and functional outcomes worsened. No improvement in range of motion was observed. Semin Arthro 22:5-9 © 2011 Elsevier Inc. All rights reserved. TE D

Hemiarthroplasty for Proximal Humerus Fractures in Patients with Parkinson's Disease

Parkinson's disease is a relatively common problem in geriatric patients with an annual incidence rate of 20.5 per 100,000. These patients are at increased risk for falls and resultant fractures. Several reports suggest total shoulder arthroplasty in patients with fractures has a relatively high rate of complications. Whether hemiarthroplasty reduces the rate of complications or improves pain or function is not known. We therefore determined the ROM, pain, complications, and rate of failure of hemiarthroplasty for management of proximal humerus fractures in patients with Parkinson's disease. We retrospectively reviewed all eight hemiarthroplasties in patients with Parkinson's disease for fracture of the proximal humerus between 1978 and 2005. Seven patients (seven shoulders) had a minimum of 2 years followup (mean, 9.9 years; range, 2-16 years). Postoperatively, the mean active abduction was 97 degrees , mean external rotation was 38 degrees , and internal rotation was a mean of being able to reach the level of the sacrum. The mean postoperative pain score was 2.5 points (on a scale of 1-5). There was a greater tuberosity nonunion in one patient and a superior malunion of the greater tuberosity in three patients. No patient had revision surgery. The benefit of hemiarthroplasty for proximal humerus fractures in patients with Parkinson's disease was marginal with three shoulders in seven patients having moderate to severe persistent pain and limited function postoperatively. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Healing of the Greater Tuberosity in Acute Shoulder Hemiarthroplasty Using an Accelerated Rehabilitation Regime

BackgroundDisplaced three- and four-part proximal humerus fractures are common and are frequently treated by shoulder hemiarthroplasty. The present study sought to evaluate an accelerated rehabilitaton regime following hemiarthoplasty and assess its affect on healing of the greater tuberosities.MethodsTwenty patients over a 2-year period treated with acute hemiarthroplasty were rehabilitated with an accelerated regime of passive movements on day 1, active movements from the second week, and strengthening from the fourth postoperative week. Clinical and radiological follow-up was at 12 months.ResultsAt 6 months, the mean Constant functional shoulder score was 55.52 (range 14 to 78). The average maximum forward elevation was 98.47° (range 30° to 160°). The mean pain score at 6 months was 11.42 (range 0 to 15). Twenty-two of 23 patients went on to heal radiologically by 3 months, with one case undergoing resorption of the tuberosities as a result of falls and a cerebrovascular event affecting the limb. At 3 months, 20/23 patients had undergone tuberosity healing with less than 0.5 cm displacement (86.9% of patients).DiscussionAn accelerated rehabilitation regime does not adversely affect the rate of healing of the tuberosities following shoulder hemiarthroplasty for proximal humerus fractures. The use of an early mobilization regime is likely to allow an earlier return to normal activities of daily living.

Pectoralis Major Insertional Ratio in Proximal Humerus Fractures: A Method to Reconstruct Humeral Head Height in Arthroplasty

A key factor for a successful outcome after hemiarthroplasty for a 4-part proximal humerus fracture is accurately restoring humeral length. Our hypothesis was that the pectoralis major insertion is not at a constant distance on the humerus, as has been previously suggested, but varies depending on the length of the humerus, and our goal was to determine if a consistent ratio exists for the insertion as it relates to total humeral length. Thirty-eight cadaver arms were dissected to expose the pectoralis major insertion. Using a digital caliper, measurements were made from the top of the humeral head to the superior aspect of the pectoralis major insertion (HP), and from the pectoralis insertion to the lateral epicondyle (PL). The predictive ability of PL for HP was examined via regression, and the average prediction error was computed. The final predictive regression model had the following formula: pHP=0.2323xPL, where pHP is predicted HP. This equation had an average prediction error of 4.11 mm. The PL can be measured intraoperatively during hemiarthroplasty for proximal humerus fractures. The proportionality relationship can then be used to predict HP with an average prediction error <5 mm. This relationship may facilitate accurate intraoperative reconstruction of prosthetic head height and enhance existing techniques for assessment of implant positioning.