Outcomes for hemiarthroplasty for proximal humeral fractures deteriorate over years

Issue: July 2010

A recently presented longitudinal outcomes study has offered mixed news on treating proximal humeral fractures with hemiarthroplasty: the first 2 years show impressive results, followed by deterioration over the ensuing 3 years.

“From 2 years to 5 years, there were an increase in pain and a decrease in acromial humeral distance, especially among the female population,” said study author Lynn A. Crosby, MD, a professor of orthopedics and director of shoulder surgery at the Medical College of Georgia in Augusta. “I suspect if I evaluated these patients at 10 years out, results would be even more dismal. It’s the old adage that nothing spoils good results like long-term follow-up.”

Eventual arthroplasty

Crosby noted that controversy exists whether the proximal humerus in these four-part fractures will lose its blood supply and, therefore “if you fix it, that the blood will develop avascular necrosis and fail, requiring an arthroplasty later.” Hence, over the past 30 years or more, treatment for these grossly displaced proximal humerus fractures (grade IV) has been hemiarthroplasty.

“But more and more of my patients have been coming back with related problems to the arthroplasty. The joint has worn out and needs to be converted to a total shoulder replacement, or the rotor cuff has failed or the tuberosities have disintegrated (osteolysis),” he said.

Crosby undertook his study to ascertain the true incidence of these adverse events “because long-term follow-up of hemiarthroplasty for fracture had not been well described in the literature.” His outcomes were presented at the 2010 Annual Current Concepts in Joint Replacement Spring Meeting (CCJR) in Las Vegas.

Decreasing acromial space

A total of 47 patients, 34 women, 13 men with a mean age 64 years old, treated by Crosby between 2000 and 2004 were available for evaluation at 2 and 5 years. Most (74%) patients suffered a fall, and the remainder a motor vehicle accident. Overall, 31 of the fractures were treated with a Bigliani/Flatow shoulder prosthesis (Zimmer, Inc.) and the remaining 16 with a fracture- specific prosthesis.

Radiographic analysis of the acromial distance — normally 7 mm to 14 mm — was 10.3 mm postoperatively, but decreased to 8.5 mm at 2 years and 6.7 mm at 5 years, which was statistically significant, Crosby said. Tuberosity osteolysis was also seen in 38% of patients at 2 years and 40% at 5 years. In addition, functional outcomes decreased from 2 to 5 years for all scoring systems used. Pain increased significantly in all patients and range of motion decreased in forward flexion and in internal rotation.

Of the 28% of patients who required revision surgery, 77% were women, mostly secondary to tuberosity osteolysis.

Crosby attributes the worsening results over the years to an elderly population that has had a significant injury. “The bone is not of very good quality for the attachment onto the rotor cuff,” Crosby told Orthopedics Today. “As time goes on, the rotor cuff fails, and then the arthroplasty kind of dislocates superiorly.”

Because of the deteriorating results with the procedure, Crosby senses that most shoulder surgeons by trade are turning away from performing acute hemiarthroplasty in favor of a reverse ball-and-socket shoulder prosthesis. “However, long-term follow-up on this newer procedure is not available, so outcomes may not be any better than our results at 5 years,” he said. “Nonetheless, across the board now, most surgeons are trying to fix everyone with internal fixation instead of a prosthesis.” – by Bob Kronemyer

Reference:

Crosby, LA. Hemi-arthroplasty for proximal humeral fractures: early and late. Paper# 7. Presented at the 2010 Annual Current Concepts in Joint Replacement Spring Meeting. May 23-26, 2010. Las Vegas.

Lynn A. Crosby, MD, can be reached at Medical College of Georgia, Department of Orthopaedic Surgery, 937 15th St., Augusta, GA 30912; 706-721-4314; e-mail: lycrosby@mcg.edu.

The study presented by Dr. Crosby and colleagues raises some critically important points that warrant further discussion and ultimately much more clinical research in this area. Namely, what do we do with elderly patients who suffer displaced complex proximal humeral fractures? In general, I agree completely with Dr. Crosby that many surgeons are turning towards internal fixation as opposed to hemiarthroplasty whenever possible. However, complication rates due to modern locking plate technology are likewise skyrocketing with increased use around the world. It has always been well appreciated that hemiarthroplasty for fractures has a high success rate with respect to pain relief, but more unpredictable in functional return. This is due almost entirely to the status of the tuberosities and their ability to heal leading to normal rotator function. Tuberosity failure to heal is the leading cause of catastrophic failure for these patients.

Therefore, concern about tuberosity failure following hemiarthroplasty and hardware failure after ORIF has led surgeons to explore the use of reverse shoulder replacements for acute 4-part fractures. While it is intriguing to lean in this direction (decreased rehabilitation, less concern for tuberosity healing to allow active function above the head) this procedure is certainly not without its own set of complications including dislocation, prosthetic instability, hematoma development, and infection. In the end analysis, Dr. Crosby’s study poses more questions than it solves for the dilemma, but studies like these pave the way for a better understanding of the best treatment options for complex shoulder problems in the future.

– William N. Levine, MD
Professor of Orthopedic Surgery and Chief of Sports Medicine
Columbia at New York-Presbyterian Hospital