Use hemiarthroplasty for proximal humeral fractures

Technical difficulty and cost differences make this the better choice for acute fractures.

Issue: October 2007

ByDavid M. Dines, MD

In my opinion, reverse shoulder prostheses (RSP) should not be used to treat primary proximal humerus fractures. While I agree with Dr. Galatz that in some rare cases, such as fractures associated with massive rotator cuff tears or significant metaphyseal comminution, one could consider the use of a primary RSP, when one considers the technical issues and published results, in the great majority of cases, primary hemiarthroplasty is the procedure of choice.

It is important to remember that in the United States most proximal humerus fractures are handled by surgeons who treat one or two cases per year. While both hemiarthroplasty and RSP are technically demanding procedures, there is little debate that reverse prosthesis procedures are more difficult. In fact, implanting an RSP, especially in the setting of a fracture, may be outside the skill set of most general orthopaedic surgeons.

David M. Dines, MD
David M. Dines

The reverse shoulder prosthesis has become extremely popular in Europe. However, in most reports the complication and reoperation rates for all indications, including trauma, are quite high. Potential complications include hematoma, infection, instability, component loosening, and cosmetic issues. It is true that in many series that look at the results of RSP, a majority of the patients have satisfactory outcomes. But, it is important to realize that these are patients who usually have a longstanding history of pain and disability; their improvements after surgery are measureable. Elderly patients with fractures typically have not had the same presurgery issues of pain and dysfunction, so their results may not seem as reasonable in this traumatic group.

A salvage procedure

Few reports discuss the results of RSP for acute fractures; most concern their use for the sequelae of fractures. Frankle et al. reported a complication rate of 28%; he concluded that it is a salvage procedure. Boileau et al., in a small group of patients treated with RSP for the sequlea of fractures, noted an improvement in Constant scores from 20 to 54 but also felt that this should be considered as a salvage procedure. In a recent study presented at the Nice Shoulder Meeting 2007, there was a complication rate of 25% in 23 patients. Many of these patients developed scapular notching, which may herald future problems.

Now, it is important to understand that both procedures (hemiarthroplasty and RSP) are very difficult. Proximal humerus fractures that require an arthroplasty are difficult fractures to treat. However, by following the principles that have been elucidated over the years, one can expect good results with this procedure. The principles include placement of the prosthesis at the correct height and version with good fixation. And, as Dr. Galatz alluded to, we must reconstruct the tuberosities in their normal position to encourage healing and to restore rotator cuff function.

We do not have time to cover all aspects of performing a hemiarthroplasty for a proximal humerus fracture in detail, however, below I have outlined certain aspects of the procedure that can help us to achieve the principles mentioned above.

Preoperative templating and intraoperative measurements help us to achieve appropriate humeral height. We often obtain scanograms of the opposite arm to get exact measurements. Then, intraoperatively, one of the many fracture positioning devices helps achieve the measured height. We prefer this intramedullary device, which when used with preoperative templating, facilitates proper component placement and subsequent tuberosity reconstruction.

Achieving appropriate version of the humeral component is just as important. Pascal Boileau has shown that too much retroversion of the component will affect tuberosity reconstruction. Clearly, once prosthesis position is confirmed, proper cement technique is used. At the time of surgery, we always assess the glenoid for damage, and, if it is problematic, which is very rarely the case, we could consider replacement.

Tuberosity reconstruction

Tuberosity reconstruction is critical. We want to place them in their appropriate positions and then rigidly fix them with longitudinal and translational sutures to both the humeral shaft and to themselves. We want to end with the tuberosity approximately 5 mm below the top of the head of the humeral prosthesis, which provides for the best functional outcome.

Now, many authors have shown that the results of hemiarthroplasty for fracture are dependent on age and time of the surgery, as well as the results of the tuberosity reconstruction. If the principles outlined above are followed, one can reasonable expect good to excellent results in most cases. That being said, complications do exist. Tuberosity reconstruction failure is probably the most important one, but instability, infection and other issues have been reported.

So, to summarize, why should you not use an RSP for acute proximal humerus fractures? It is a very difficult procedure, even in the most skilled of hands. And, again, most surgeons treating these fractures only treat a few per year. Rotator cuff tears are not common in this group, which would be one of the rare times I would even consider using a reverse for acute fractures. The complication and reoperation rate is significantly higher in patients treated with RSP compared to hemiarthroplasty.

Last, but not least, I think we must talk about cost. Conventional prostheses in the United States cost about $3,000; RSPs cost about $8,000, which doesn’t include the increased incidence of complications and potentially longer hospital stays. Remember, the decision-making process in these cases is based on risk and reward. I doubt that most people in the community want to take on the increased risk and cost of an RSP in these difficult cases.

For more information
David M. Dines, MD, can be reached at 935 Northern Blvd. #303, Great Neck, NY 11021-5309; 516-482-1037; e-mail: ddinesmd98@aol.com. He indicated that he is a consultant for Biomet.
Reference:
Dines DM. Reverse shoulder replacement: Forward thinking in acute fx? Paper #6. Presented at Current Concepts in Joint Replacement Spring 2007. May 20-23, 2007. Las Vegas.