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Improved fixation methods and prostheses lead to better tuberosity healing
Advances in implant materials, fixation methods and the use of conservative rehabilitation have resulted in greater tuberosity healing.
“There are fewer indications for humeral head replacement because we have these better percutaneous options,” Evan L. Flatow, MD, said during his presentation at Orthopedics Today Hawaii 2012.
Improved stems, positioning
Prosthetic stems now have more space for tuberosities and some are made of ingrowth materials such as tantalum or have “little spikes” that hold the tuberosity, Flatow said. He cited a study by Krishnan and colleagues in which patients who underwent proximal humeral hemiarthroplasties with fracture-specific stems showed greater healing and function in their injured shoulders compared to patients who did not receive fracture-specific stems.
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Surgeons also have better methods to ensure correct positioning of the head.
“If you put the tuberosity too far distally, you will tension the cuff around the head and cause a tendency for that tuberosity to pull off,” Flatow said. “[If] you put it too high, you may get impingement and will also not have a good surface for healing.”
Flatow uses a “jigsaw puzzle method,” in which he uses the fractured head to choose an anatomic replacement of the same size and curvature, reconstructs the fractured humerus to see the height of the native head above a shaft landmark, and then sets the prosthetic head at the same height.
“You are only going to be off by a few millimeters,” Flatow said. “Whereas in the old days, we would simply take the shaft and just play around with trying to put a stem on it and try to figure out the height. This is a much more straightforward way of doing it.”
Malposition also affects tuberosity healing, Flatow said. He cited a 2002 study conducted by Pascal Boileau, MD, and colleagues in which 33 of 66 patients showed malpositioning as a result of excessive height or retroversion of the prosthesis. This lead to superior migration of the prosthesis, stiffness or weakness, and persistent pain.
In cases of excessive retroversion, orthopedists must bring arms into internal rotation in a sling position, which puts pressure on the tuberosity and “knocks it off,” he said.
“Moving toward a more anatomic retroversion and fracture situation can actually unload the greater tuberosity and make it less likely to pull off as time goes on,” Flatow said.
Rehabilitation, fixation
Surgeons once used sutures during fixation that “came down to the shaft,” which overreduced the tuberosity and made the shoulder stiff. Now, some use cerclage wires around the medial side of the prosthesis. Flatow warned that too many suture may strangulate the blood supply to the soft tissues.
“You want to construct [where] there is not much exposure, but you have not stripped everything. You have living tissue, and yet, you have the secure fixation,” he said.
Flatow recommends using cables instead of wires because they do not tend to break and achieve a more stable fixation. However, he warned not to use them in elderly patients with osteoporotic, comminuted tuberosities.
More conservative rehabilitation instead of “immediate aggressive motion” after a few weeks of healing may also assist with tuberosity healing, Flatow said.
“I think greater tuberosity healing can be approached systematically,” he said. “We are certainly better than we were 10 to 15 years ago.” – by Renee Blisard
References:
- Flatow EL. Tuberosity, tuberosity, tuberosity! How to get them to heal in HHR. Presented at Orthopedics Today Hawaii 2012. Jan. 15-18. Wailea, Hawaii.
- Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002; 11(5):401-412. doi: 10.1067/mse.2002.124527.
- Krishnan SG, Reineck JR, Bennion PD, et al. Clin Orthop Relat Res. 2011; 469(12):3317-3323. doi: 10.1007/s11999-011-1919-6.
For more information:
- Evan L. Flatow, MD, can be reached at Mt. Sinai Medical Center, 5 E. 98th St., 9th Floor, New York, NY 10029; 212-241-8892; email: evan.flatow@msnyuhealth.org.
- Disclosure: Flatow receives royalties from Zimmer and Innomed.
Perspective
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Dr. Flatow has given a nice review of the current thinking on the role of humeral head replacement in the management of displaced proximal humeral fractures. Other surgical options including percutaneous pinning, open reduction and internal fixation with locked plating and improved humeral nails, and reverse total shoulder arthroplasty have significantly curtailed the use of standard hemiarthroplasty for complex fractures.
The main concern regarding hemiarthroplasty for fracture is the catastrophic complication of tuberosity healing. If tuberosity failure occurs, patients will suffer catastrophic outcomes with pseudoparalysis, pain, and loss of normal function.
Dr. Flatow provides a modern step-wise approach to enhance tuberosity healing and highlights the following: use of modern prostheses that are either fracture-specific or have features to enhance bone healing; recreate normal head height and humeral retroversion (10° to 20°, not 30° to 40° as previously thought); use of horizontal cerclage type sutures as opposed to vertical tuberosity-shaft sutures; and conservative and slow rehabilitation to allow time to heal.
While the indications for hemiarthroplasty for fracture are decreasing, attention to the technical tips provided by Dr. Flatow will enhance tuberosity healing, and lead to improved and more predictable patient outcomes.