Tuberosity Healing Research Articles

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.

The role of teriparatide in tuberosity healing after reverse shoulder arthroplasty in complex proximal humeral fragility fracture.

Tuberosity healing is known to be one of the factors that increase functional outcome in Reverse Total Shoulder Arthroplasty (rTSA). In fragility fractures, tuberosity healing is difficult to be achieved. The fragment stability and bone-forming agent application become strategies to overcome this problem. The purpose of this study was to evaluate the benefit of teriparatide application to promote tuberosity union in rTSA on four-part proximal humeral fractures to achieve better functional outcome. A retrospective study of a prospectively collected shoulder arthroplasty medical record was performed. Eleven patients were included in this analysis and consisted of two groups, teriparatide and no-teriparatide groups. Patients were evaluated on the range of motions and clinical outcome using the American Shoulder Elbow Surgeon (ASES) Shoulder Score and X-ray to determine tuberosity union. The group differences were analyzed by t-test or Mann-Whitney U test with SPSS version 20.0 for Windows. The statistical analysis revealed no significant differences in mean age in both the groups. There were significant differences between teriparatide and no-teriparatide groups in external rotation (29.5° vs. 7.5°; p = 0.004), external rotation in 90° abduction (55° vs. 12.5°; p < 0.020), forward flexion (120° vs. 105°; p = 0.002) range of motions, and ASES (84.5 vs. 74.6; p = 0.019). We found clinical difference between teriparatide and no-teriparatide groups in time to achieve the initial callus (33 ± 18.3 days vs. 150 ± 42.4 days) and tuberosity consolidation (165.8 ± 70.3 days vs. 315 ± 106.1 days). Teriparatide administration supports tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after rTSA in acute complex proximal humeral fractures.

Reverse shoulder arthroplasty for the treatment of acute complex proximal humeral fractures: Influence of greater tuberosity healing on the functional outcomes.

To investigate the influence of greater tuberosity healing on the functional outcomes of reverse shoulder arthroplasty (RSA) for the treatment of acute complex proximal humeral fractures (PHFs), and to investigate the influence of patient- and surgery-related factors in the healing of the greater tuberosity. Retrospective study including 41 consecutive PHFs treated using RSA with minimum 2-year follow-up. In all the cases, tuberosities were reattached with a standardized technique. All the patients were assessed at the last follow-up with constant score. Body mass index, surgery delay, comorbidities, polyethylene size, glenosphere size, overhanging of glenosphere, and scapular notch were recorded, and their influence in final constant score and in greater tuberosity healing was analyzed. Mean final constant score was of 60.7 points (standard deviation (SD) = 9.9). Greater tuberosity healed in proper position in 68% of the cases. There were no significant differences in constant score between patients with (mean = 61; SD = 9.5) and without (mean = 61; SD = 11.3) the healing of greater tuberosity. All patients scored above 90° in forward elevation. Scapular notch was reported in 14.6% of the cases. Age significantly affected the constant score ( p = 0.008). Comorbidities significantly interfered with greater tuberosity healing ( p = 0.03). There was one reoperation after dislocation. In spite of expecting good functional outcome with low complication rate after RSA for acute PHFs, the influence of greater tuberosity healing on shoulder function could not be demonstrated. The presence of comorbidities, but not age or gender, negatively influenced the healing of the greater tuberosity.

Humeral Head Replacement and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fracturesm.

Acute proximal humeral fractures in the elderly are generally treated non-operatively if alignment is acceptable and in stable fracture patterns. When operative treatment is indicated, surgical fixation is often difficult or impossible to obtain. Hemiarthroplasty has long been the standard of care. However, with its reliance on tuberosity healing, functional outcomes and patient satisfaction are often poor. Reverse shoulder arthroplasty has emerged as a new technology for treating proximal humeral fractures but the indications for its use remain uncertain. While not conclusive, the evidence suggests that reverse shoulder arthroplasty yields more consistent results, with improved forward elevation and higher functional outcome scores. The primary advantages of hemiarthroplasty are improved shoulder rotation and shorter operative time. Complication rates do not vary significantly between the two options. Although higher quality trials are needed to further define the role of reverse shoulder arthroplasty, current evidence suggests that this is a reasonable option for surgeons who are highly familiar with its use.

Early Versus Late Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: Does It Matter?

This study compared the outcomes between patients with proximal humerus fractures (PHF) who underwent acute reverse total shoulder arthroplasty (RSA) to those who underwent an alternative initial treatment before requiring (secondary) RSA. Patients who underwent RSA after suffering a PHF were identified. Two year clinical follow-up was required for inclusion. Patients were divided into an acute group (RSA <4 weeks of fracture) and a secondary group. The secondary RSA group was subdivided by initial treatment (non-operative, hemiarthroplasty, open reduction internal fixation (ORIF)). Clinical and radiographic outcomes were compared. Forty-seven patients met inclusion criteria with 15 in the acute RSA group and 32 in the secondary RSA group. The acute RSA group demonstrated better external rotation (28°) than the secondary RSA group (18°, P=0.0495). The acute RSA group showed a trend towards better Single Assessment Numeric Evaluation (SANE) scores. Tuberosity healing rate was higher in the acute RSA group. While acute and secondary RSA can yield successful outcomes, acute RSA results in a higher tuberosity healing rate and improved external rotation.

Reverse shoulder arthroplasty for four-part proximal humerus fracture in elderly patients: can a healed tuberosity improve the functional outcomes?

The purpose of this study was to investigate whether healed tuberosities yield better rotational range of motion (ROM) and functional outcomes compared with unhealed tuberosities after reverse shoulder arthroplasty in elderly patients with comminuted proximal humerus fractures. This study included 38 patients who underwent reverse arthroplasty because of 4-part proximal humerus fractures; 14 patients had healed tuberosities (group A) and 24 patients had unhealed tuberosities (group B). Functional assessments included visual analog scale pain score, American Shoulder and Elbow Surgeons score, Constant score, and active ROM. There were no significant differences in the patients' demographics between the 2 groups. At final follow-up, no significant differences were found between groups in visual analog scale score (group A, 1.4; group B, 1.6; P = .647), American Shoulder and Elbow Surgeons score (74.3 and 70.7; P = .231), and Constant score (67.9 and 63.9; P = .228) and ROM with forward flexion and internal rotation. However, in external rotation, there was a significant difference between groups (29° and 10° in external rotation with the elbow at the side [P < .001]; 25° and 7° in external rotation with shoulder abduction [P < .001]). After reverse shoulder arthroplasty for 4-part proximal humerus fracture, tuberosities were healed in an anatomic position in 37% of patients. However, there were no significant differences in functional outcomes and ROM between the 2 groups, with the exception of external rotation, which was better in the healed tuberosity group. Therefore, tuberosity healing is not a prerequisite for satisfactory outcomes after reverse shoulder arthroplasty for 4-part proximal humerus fractures in elderly patients.

Functional outcome after primary hemiarthroplasty in three or four part proximal humerus fracture: A short term followup.

Background:Several modalities of treatment are being used for the management of proximal humerus fractures. Primary hemiarthroplasty in proximal humerus fracture is indicated in three or four part fracture or fracture dislocations. It is also indicated if fracture involves a large area of articular cartilage loss and viability of head is doubtful. We studied the functional outcome of hemiarthroplasty in comminuted proximal humerus fracture.Materials and Methods:29 patients of three or four part proximal humerus fractures, (according to Neer's classification) who underwent primary shoulder hemiarthroplasty were included in this retrospective study. 20 patients were of more than 55 years of age. Functional evaluation based on Constant score and radiological assessment by periodic X-rays were done. All patients were operated in a ‘beach chair position’. The lesser and greater tuberosities were dissected with their tendinous attachments and were later reattached to the proximal humerus for stability of the prosthesis. Cemented prosthesis was used in all cases.Results:Three patients died and two patients were lost to followup during the course of the study, so 24 patients were finally included in the study. Mean Constant score was 56.62 (range 42.5-65.5) after mean followup of 18.28 months (range 12-24 months). Mean anterior elevation was 118.2° (range 75°-150°) and mean active abduction was 102°(range 50°-135°). Nineteen patients (79.16%) were satisfied about their functional outcome. Proximal migration of tuberosity was present in four patients. These patients had decreased abduction with impingement. One patient had higher placement of prosthesis and one patient had radiolucency at bone cement interface. There were no heterotopic ossification, dislocation, superficial, or deep infection.Conclusion:This study showed that hemiarthroplasty in a grossly comminuted proximal humerus fracture is a viable alternative to osteosynthesis. Tuberosity healing plays a main role in good range of motion and better functional outcome after shoulder hemiarthroplasty.

Cement technique correlates with tuberosity healing in hemiarthroplasty for proximal humeral fracture

Tuberosity healing correlates with clinical outcomes after hemiarthroplasty for 4-part proximal humeral fractures (4PHFs). We seek to examine variables that affect tuberosity healing. This was a retrospective comparative study. At 1 year postoperatively, patients who underwent hemiarthroplasty for 4PHFs were divided into 2 groups: those with anatomically healed tuberosities and those with tuberosity nonunion. The primary variables included time between injury and surgery, prosthesis fenestration, cement mantle classification, and both vertical and horizontal tuberosity reduction. Secondary demographic factors included age, gender, osteoporosis status, diabetes status, and smoking status. There were 84 individuals who met the inclusion criteria: 37 (44%) had anatomically healed tuberosities, and 47 (56%) did not. Individuals with anatomic healing had cement near or under the tuberosities 32% of the time, whereas individuals with nonunion or resorption had cement near the tuberosities 66% of the time (P = .002). There was no association between tuberosity healing and fenestration of the humeral stem (P = .84). Anatomic reduction between tuberosities was associated with healing (P <.001), whereas greater tuberosity-to-head height was not (P = .25). There were no significant differences in age, osteoporosis status, smoking status, diabetes status, or time to surgery between groups. Male patients had nearly double the rate of healing (P = .03). The classification and effect of cement technique on tuberosity healing have not previously been described. We suggest limiting cementation to a minimum of 5 mm below the level of the tuberosity fracture. The ideal candidate for hemiarthroplasty for a 4PHF is a male patient with anatomic tuberosity reduction and limited use of cement.

Paper #17 - Surgeon-controlled variables for tuberosity healing after shoulder hemiarthroplasty for fracture

Paper #17 - Surgeon-controlled variables for tuberosity healing after shoulder hemiarthroplasty for fracture

(ii) Hemiarthroplasty of the glenohumeral joint

Abstract Hemiarthroplasty of the humeral head is indicated for glenohumeral arthritis unresponsive to conservative measures and for some acute fractures of the proximal humerus. Regardless of indication, the functional result relies upon recreation of normal anatomy. In the elective setting, stemmed, stemless and surface replacement prostheses are available. Significant controversy exists regarding implant choice, and a longstanding debate concerning the choice of hemiarthroplasty versus total shoulder replacement continues. Complex fractures of the proximal humerus may not be reconstructable or may place the humeral head at excessive risk of avascular necrosis. Stemmed prosthetic replacement is often performed for such indications. This is a technically challenging procedure for which results are related to the healing of the bony tuberosities which in turn provides best rotator cuff function. Tuberosity healing is though to be related to good surgical technique. This article aims to review the history, indications, technique and results of prosthetic hemiarthroplasty of the shoulder. Where available, comparison of results is made with alternative prosthesis designs and with other available forms of glenohumeral arthroplasty for each indication.

Reverse shoulder arthroplasty for proximal humerus fracture using a dedicated stem: radiological outcomes at a minimum 2years of follow-up-case series.

BackgroundComplex proximal humeral fractures are very difficult to treat particularly in patients older than 65 years with an osteoporotic bone and tuberosities compromised. The goal of this paper is to evaluate radiological outcomes at mid-term follow-up of proximal humerus fractures treated with reverse shoulder arthroplasty using a dedicated fracture stem.Materials and methodsThe study population included 98 patients who underwent reverse shoulder with a dedicated fracture stem for an acute proximal humerus fracture; 87/98 patients were available for analysis. There were 62 female and 25 male patients, and the mean age was 76.2 years at the time of surgery (range 61–90 years). Clinical and radiological outcomes were evaluated at a mean follow-up of 27 months after surgery.ResultsAverage active elevation was 137.7°, external rotation 29.1°, and internal rotation 40.7°. Overall, the tuberosity healing rate was 75 %. There was a significant increase in active anterior elevation, external rotation, and internal rotation among patients who demonstrated radiographic evidence of tuberosity healing. All tuberosity nonunions (21 cases) occurred preferentially in females, but this number did not reach statistical significance.ConclusionRSP using a dedicated stem is a very viable solution to treat complex humerus proximal fracture. Reliable restoration of elevation can be expected. However, in patients in whom tuberosity healing occurs, a better active elevation other than restoration of active rotational movement can be observed.

Tuberosity healing after reverse shoulder arthroplasty for acute proximal humerus fractures: the “black and tan” technique

Reverse shoulder arthroplasty has seen increased use for management of complex proximal humeral fractures in the elderly. Recent evidence has shown that tuberosity healing leads to improved active range of motion and functional outcomes. The purpose of this study was to report on the radiographic and clinical outcomes of a consecutive series of patients having undergone reverse shoulder arthroplasty for fracture utilizing the "black and tan" method--a hybrid cementation-impaction grafting technique that uses autogenous cancellous bone graft to create an interface between the proximal cement mantle and the area of tuberosity repair. Twenty-five patients (average age, 77 years; range, 63-88 years) were included in the analysis with a mean follow-up of 17 months. All patients underwent reverse shoulder arthroplasty for a complex proximal humerus fracture using the black and tan technique. The tuberosity healing rate was 88%. At final follow-up, mean active elevation was 117° ± 23°, mean abduction was 86° ± 16°, and mean external rotation was 29° ± 18°. External rotation strength averaged 4.9 ± 0.2. The Simple Shoulder Test and Single Assessment Numeric Evaluation scores averaged 7 and 76, respectively. The mean American Shoulder and Elbow Surgeons total score was 71; visual analog scale score for pain, 2; and visual analog scale score for function, 7. Of the 25 patients, 21 (84%) rated their satisfaction with the surgery as excellent or good. The black and tan technique together with standard suture repair and an implant with features that support tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after reverse shoulder arthroplasty for fracture.

Hemiarthroplasty versus reverse shoulder arthroplasty: comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture

To compare functional and radiographic results of reverse prosthesis versus hemiarthroplasty after complex displaced proximal humeral fractures in elderly patients when adequate ORIF cannot be achieved and prosthetic shoulder replacement is required. From 2008 to 2012, 67 patients were treated with hemiarthroplasty or reverse arthroplasty. We evaluated 53 cases with an average follow-up of 27.5months (range 12-64). Twenty-eight patients with an average age of 71.4years were treated with a hemiarthroplasty and 25 patients with an average age of 77.3years with a reverse prosthesis. All patients were assessed before and after surgery by Constant-ASES-DASH score, strength in abduction, ER1, ER2, and X-rays. In hemiarthroplasty group, we observed a mean Constant score of 42.3pt, ASES score 51.3pt, and DASH score 46.1, with an average strength of 1.3lb in abduction and of 3.7lb in ER1 and 1.8lb in ER2. In reverse arthroplasty group, we measured a mean Constant of 56.2pt, ASES 69.3pt, and DASH score 40.4, with an average strength of 4.3lb in abduction and of 3.3lb in ER1 and 3.2lb in ER2. Radiographically, it is interesting to observe that greater tuberosity healing rate was 37% in hemiarthroplasty group compared to 84% in reverse arthroplasty group. About complications, the highest rate was recorded in the hemiarthroplasty group. Reverse shoulder arthroplasty indication is steadily increasing in acute displaced proximal humeral fracture. Pain and articular movement results appear better than those with hemiarthroplasty. Our data are similar to the international literature.

Proximal humerus fractures should be treated with a reverse shoulder replacement

Historically, fractures of the proximal humerus not amendable to closed treatment or internal fixation have been treated with hemiarthroplasty. Clinical outcomes following hemiarthroplasty have been variable and difficult to predict. Results are often correlated with increasing age, tuberosity healing, and tuberosity position. Reverse shoulder arthroplasty has demonstrated effectiveness in elderly patients with rotator cuff arthropathy and has been increasingly employed for complex fractures in older patients. Several small trials have compared the reverse arthroplasty and hemiarthroplasty for acute fractures, and reverse shoulder arthroplasty has demonstrated more reproducible results in elderly patients.

Reverse shoulder arthroplasty for proximal humerus fractures

A reverse shoulder arthroplasty is a consideration for the treatment of comminuted four-part proximal humerus fractures in elderly patients. While a reverse TSA should not replace other treatment modalities, it is indicated in elderly patients with fractures that are not amenable to fixation. Immediate stability and relative independence from tuberosity healing are clear advantages, but the complication rate is substantially higher. Larger studies are necessary to clarify appropriate indications.

Proximal Humeral Fracture Treatment in Adults

Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.

Comparison of Hemiarthroplasty and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures in Elderly Patients

Treatment of complex three and four-part proximal humeral fractures with hemiarthroplasty in elderly patients has yielded mixed clinical results. Reverse shoulder arthroplasty has emerged as a treatment option for comminuted proximal humeral fractures for these patients. The purpose of the study was to perform a prospective evaluation of patient outcomes comparing hemiarthroplasty and reverse shoulder arthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients. Fifty-three consecutive elderly patients (average age, 74.4 years) underwent an arthroplasty for a complex proximal humeral fracture. Indications for arthroplasty were four-part fractures, three-part fractures with severe comminution of the greater tuberosity, and fractures that involved an articular split of the humeral head. Twenty-six patients underwent hemiarthroplasty (the HA group), followed by twenty-seven patients who underwent reverse shoulder arthroplasty (the RSA group). A total of forty-seven patients (twenty-three in the HA group and twenty-four in the RSA group) were available for follow-up at a minimum of two years. Final average outcome scores were lower in the HA group than in the RSA group (American Shoulder and Elbow Surgeons [ASES] score of 62 versus 77 [p = 0.0001] and Simple Shoulder Test [SST] of 5.8 versus 7.4 [p = 0.0062]), and patient-reported satisfaction was lower in the HA group than in the RSA group (61% versus 91%; p = 0.038). Radiographic healing of the tuberosities occurred in 61% of the patients in the HA group compared with 83% of the patients in the RSA group (p = 0.17). Forward elevation of the arm was higher in the RSA group (139°) than in the HA group (100°) (p = 0.0002), but no significant differences were observed for shoulder external rotation or internal rotation. Complication rates in both groups were similar. Three patients (13%) in the HA group elected revision to reverse shoulder arthroplasty because of failed tuberosity healing and resultant shoulder pseudoparesis. In this series, reverse shoulder arthroplasty resulted in better clinical outcomes and a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the elderly.

Avoiding Cement Bone Necrosis Effect on Tuberosity Healing

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Can surgeons predict what makes a good hemiarthroplasty for fracture?

The purposes of this study were (1) to identify the risk factors for tuberosity complications and poor functional outcomes and (2) to compare a standard humeral stem with a fracture-specific humeral stem in hemiarthroplasty for the treatment of 3- and 4-part proximal humeral fractures. We retrospectively reviewed the cases of 60 consecutively operated patients (61 shoulders) using radiographs and computed tomography scans. There were 56 displaced four-part and 5 three-part fractures. The technique was standardized for prosthesis positioning in height and retroversion and for tuberosity fixation. A conventional standard stem was implanted in the first 31 shoulders (group A), and a specific fracture stem was implanted in the next 30 shoulders (group B). The sample size needed for comparison was predetermined with an a priori power analysis. The mean follow-up period was 64 months (range, 24 to 150 months). At the last follow-up, the greater tuberosity was healed in an adequate (anatomic) position in 45% of the patients in group A (14 of 31) and 87% of those in group B (26 of 30) (P = .0001). Active forward elevation, active external rotation, and the Constant score were significantly better with fracture stems (136°, 34°, and 68 points, respectively) than with conventional stems (113°, 23°, and 58 points, respectively) (P < .0001). Regardless of the type of implant used, patients aged 75 years or older and women had significantly lower functional results and higher rates of tuberosity complications (P < .0001). Good functional outcomes can be anticipated after hemiarthroplasty for proximal humeral fractures if the greater tuberosity is anatomically positioned (ie, lateral to the stem) and healed around the prosthesis. The use of a specific fracture stem allows to double the rate of tuberosity healing compared to a conventional stem (87% vs. 45%), decreases complications and improves shoulder function. Risk factors associated with poor functional results and anatomic failures are (1) patient age (≥75 years), (2) patient gender (women), and (3) use of a conventional (bulky) stem.

Unconstrained Shoulder Arthroplasty for Treatment of Proximal Humeral Nonunions: Surgical Technique.

Anatomic unconstrained arthroplasty for the treatment of proximal humeral nonunion is challenging and may require management of rotator cuff tearing or scarring, glenohumeral instability, shoulder capsule fibrosis, poor bone quality and bone defects, and glenohumeral arthritis and may require internal fixation and bone-grafting for stimulation of healing. Obtain anteroposterior, axillary, and lateral scapular Y views of the shoulder to assess the fracture for the size and position of the humeral head, humeral shaft, and greater and lesser tuberosities as well as for fracture nonunion. In cases with substantial contracture or difficult exposure, use an anteromedial approach. For three and four-part fractures, secure the tuberosity fragments with strong sutures and then mobilize them from the articular fragment and the humeral shaft. The tuberosity bone fragment should be reduced to the prosthesis with positioning 6 to 10 mm below the top of the humeral head component. Fixation of the humeral stem usually requires cement, but avoid cement in the area of the tuberosity nonunion to help prevent necrosis of the bone resulting in further nonunion. To achieve tuberosity healing in anatomic alignment, reduce the tuberosities anatomically followed by bone-grafting and rigid fixation. Patients use a shoulder immobilizer for six weeks, begin formal physical therapy at two to four weeks, and initiate a shoulder strengthening program at about ten to twelve weeks. The management of proximal humeral nonunion is challenging and historically results have shown reasonable pain relief with limitations in function. IndicationsContraindicationsPitfalls & Challenges.