Tuberosity Healing Research Articles

Reverse Prosthesis for Proximal Humerus Fracture, Technique and Results

The reverse prosthesis has become a treatment of choice for glenohumeral osteoarthritis in a cuff-deficient shoulder. It allows restoration of mobility despite the loss of rotator cuff function. Hemiarthroplasty, the historical standard of care for proximal humeral fractures requiring replacement, fails most commonly because of tuberosity nonunion. Therefore, in the face of poor bone quality, the reverse prosthesis is a logical choice for acute fractures to improve postoperative mobility in elevation regardless of tuberosity healing. Nevertheless, the healing of the tuberosities may influence the recovery in active external rotation. The purpose of this article is to report on the superolateral technique to implant a reverse shoulder prosthesis for acute proximal humeral fractures, emphasizing the technique of tuberosity fixation, and to analyze previously published series. Considering the follow-up and complication risks, the reverse prosthesis should be reserved for fractures involving elderly patients. The decision to use a reverse prosthesis for an acute fracture should be based on a thoughtful risk-benefit analysis between hemiarthroplasty and reverse shoulder arthroplasty.

Prosthetic Version and Healing of the Greater Tuberosity: Their Influence on Functional Outcome in Implanted Hemiarthroplasties due to Fractures of the Proximal Humerus

To determine the influence of the prosthesis used and of greater tuberosity healing on the final functional result of shoulder hemiarthroplasties due to fracture of the proximal third of the humerus. This was a prospective study of 32 hemiarthroplasties with a mean followup of 43.51 months. X-ray control was carried immediately after surgery and at the end of the followup to assess the reduction of the greater tuberosity. Also at the end of the followup axial CAT scans (implant retroversion study), a functional assessment (Constant functional scale), and a health status determination (EuroQol-5D) were performed. The mean global value of the Constant scale for this series was 61.12. As to retroversion: values of 20–40° were seen in 8 patients, 0–20° in 20 patients and anteversion >0 in 4 patients. When the prosthesis model variable was compared using the Constant scale to determine functional outcome, no significant differences were seen (p=0.558). However, there was a trend to a better value in the Constant scale when the version of implant used was more anatomical, but this was not statistically significant. There was a correlation between the quality of immediate postoperative reduction of the greater tuberosity, healing of the greater tuberosity and final functional outcome. There was a trend towards worse functional outcome in hemiarthroplasties with retro and anteversion values that were further from normal, but this was not statistically significant. Determinar la influencia de la versión protésica y la consolidación de la tuberosidad mayor en el resultado funcional final de las hemiartroplastias de hombro por fractura del tercio proximal de húmero. Estudio prospectivo de 32 hemiartroplastias con un seguimiento medio de 43,51 meses. Se ha efectuado un control radiológico en el postoperatorio inmediato y al final del seguimiento para evaluar la reducción obtenida del troquíter. También al final del seguimiento se ha realizado un estudio mediante tomografía axial computarizada (estudio de retroversión del implante), una evaluación funcional (escala funcional de Constant) y una valoración del estado de salud (EuroQol-5D). El valor global medio de la escala de Constant de la serie fue de 61,12. En cuanto a la retroversión, en 8 pacientes se obtuvo un valor entre 20-40°, en 20 pacientes un valor entre 0-20° y en 4 pacientes anteversión superior a 0°. Al comparar la variable versión protésica con el resultado funcional mediante la escala de Constant no se encontraron diferencias significativas (p = 0,558), aunque existe una tendencia hacia un mejor valor en la escala de Constant cuanto más anatómica sea la versión del implante. Existe una correlación entre la calidad de la reducción postoperatoria inmediata de la tuberosidad mayor, la consolidación de la misma y el resultado funcional final. Existe una tendencia a presentar un peor resultado funcional en aquellas hemiartroplastias cuya colocación se aleja más de los valores considerados como normales de versión, aunque sin significación estadística.

Early versus late mobilization after hemiarthroplasty for proximal humeral fractures

This randomized controlled trial compares 2 mobilization regimens after shoulder hemiarthroplasty for acute 3- and 4-part fractures. The aim was to establish whether the length of immobilization plays a role in the functional outcome, tuberosity healing, and subsequent range of motion. The same prosthesis and surgical technique were used. We recruited 59 patients into the study; 31 were randomized to early (2 weeks) mobilization and 28 to late (6 weeks) mobilization. Greater tuberosity migration was assessed with a series of radiographs, and the functional outcome was assessed with the Constant Shoulder Assessment and Oxford shoulder scores. Of the patients, 49 (mean age, 70 years) met the inclusion criteria and were followed up for 12 months. Greater tuberosity migration occurred in 3 cases in the early mobilization group and once in the late mobilization group (P > .10). There was no significant difference in the Constant Shoulder Assessment and Oxford scores between the 2 groups. Although there was a decreased incidence of tuberosity migration in the group undergoing late mobilization, this was not statistically significant.

Early complications of operatively treated proximal humeral fractures

Minimal information exists regarding early complications after operatively treated proximal humeral fractures. Of the 82 shoulders that had osteosynthesis, 42 had a (nonmedical) complication, with 21 requiring further surgery. Of 42 shoulders with complications, 12 were related to incomplete reduction, 16 had loss of anatomic fracture fixation, 9 had delayed healing, 3 had an infection, 1 had rotator cuff failure, and 1 had loose bodies. Fixed-angle plates had lower rates of initial malpositioning and resultant malunion. Of the 22 shoulders requiring hemiarthroplasty, 14 had an early complication. Of these, 7 had complications relating to implant insertion or tuberosity malreduction at the index operation and 7 had problems with tuberosity healing. The rate of complications after operative treatment of proximal humeral fractures is high. All efforts at fracture fragment fixation with osteosynthesis and hemiarthroplasty should be directed at obtaining anatomic fracture fixation that resists displacement.