Advertisement

Fix or Replace?

  • Paolo Paladini
  • Giovanni Merolla
  • Carlo Alberto Augusti
  • Giuseppe Porcellini
Chapter

Abstract

Proximal humeral fractures account for about 10% of all fractures, and the incidence is increasing. The majority of minimally displaced fractures are successfully treated nonoperatively, but the optimal management of displaced or complex fracture remains controversial. Devascularization of the humeral head, associated injury to the rotator cuff, and the high prevalence of osteoporosis in elderly patients make the decision-making and the treatment very challenging. Current evidences are not able to give a useful guideline among prosthetic replacements, intramedullary nails, fixed angle locked plates, and conservative methods. Arthroplasty surgery should be more useful in fracture pattern, in which the humeral head is at risk of avascular necrosis, while internal fixation should be better in a fracture pattern, whereby the risk of devascularization is low. Different fracture patterns have been associated with a higher risk of humeral head necrosis: medial metaphyseal head extension more than 8 millimeters, disruption of the posteromedial hinge, and any fracture disrupting the anatomical humeral head. The presence of any of these features should prompt the clinician to consider arthroplasty surgery as a more reliable treatment option. Reverse total shoulder arthroplasty (RTSA) appears to provide range of motion superior to that of hemiarthroplasty (HA) and open reduction and internal fixation (ORIF). RTSA predictably restored active elevation over horizontal plane in all patients within 4 months. RTSA realized even significant cost savings compared with ORIF and HA.

Conclusion: Summarizing, the elderly patients treated with reverse total shoulder arthroplasty had better clinical outcomes, better forward elevation, higher tuberosity healing rates, and a lower rate of revision surgery compared with those who had hemiarthroplasty and open reduction and internal fixation for the treatment of a comminuted proximal humeral fracture.

Keywords

Shoulder fractures Reverse total shoulder arthroplasty Hemiarthroplasty 

References

  1. 1.
    Jordan RW, Modi CS. A review of management options for proximal humeral fractures. Open Orthop J. 2014;8:148–56.  https://doi.org/10.2174/1874325001408010148. eCollection 2014CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7:612–8.CrossRefGoogle Scholar
  3. 3.
    Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M, Vuori I. Increasing number and incidence of osteoporotic fractures of the proximal humerus in elderly people. BMJ. 1996;313:1051–2.CrossRefGoogle Scholar
  4. 4.
    Koval KJ, Gallagher MA, Marsicano JG, Cuomo F, McShinawy A, Zuckerman JD. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am. 1997;79(2):203–7.CrossRefGoogle Scholar
  5. 5.
    Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elb Surg. 2008;17:42–54.CrossRefGoogle Scholar
  6. 6.
    Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four part proximal humeral fractures. J Bone Joint Surg Am. 2009;91:1689–97.CrossRefGoogle Scholar
  7. 7.
    Neer CS II. Displaced proximal humerus fractures. Part I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–89.CrossRefGoogle Scholar
  8. 8.
    Muller ME, Allgower M, Schneider R, Willeneger H. Manual of internal fixation: techniques recommended by the AO-Group. 2nd ed. Berlin, New York: Springer-Verlag; 1979.CrossRefGoogle Scholar
  9. 9.
    Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg. 1993;75:1751–5.CrossRefGoogle Scholar
  10. 10.
    Sidor ML, Zuckerman JD, Lyon T, Koval K, Cuomo F, Schoenberg N. The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am. 1993;75:1745–50.CrossRefGoogle Scholar
  11. 11.
    Bernstein J, Adler LM, Blank JE, Dalsey RM, Williams GR, Iannotti JP. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am. 1996;78:1371–5.CrossRefGoogle Scholar
  12. 12.
    Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elb Surg. 2004;13(4):427–33.CrossRefGoogle Scholar
  13. 13.
    Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am. 2010;92:943–8.CrossRefGoogle Scholar
  14. 14.
    Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand. 2003;74:580–5.CrossRefGoogle Scholar
  15. 15.
    Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark H. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomised controlled trial. J Shoulder Elb Surg. 2011;20:747–55.CrossRefGoogle Scholar
  16. 16.
    Zyto K. Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients. Injury. 1998;29:349–52.CrossRefGoogle Scholar
  17. 17.
    Krishnan SH, Bennion PW, Reineck JR, Burkhead WZ. Hemiarthroplasty for proximal humeral fracture: restoration of the Gothic arch. Orthop Clin North Am. 2008;39:441–50.CrossRefGoogle Scholar
  18. 18.
    Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195–200.CrossRefGoogle Scholar
  19. 19.
    Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21(3):185–91.CrossRefGoogle Scholar
  20. 20.
    Owsley K, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg Am. 2008;90:233–40.CrossRefGoogle Scholar
  21. 21.
    Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21:676–81.CrossRefGoogle Scholar
  22. 22.
    Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elb Surg. 2000;9:423–46.CrossRefGoogle Scholar
  23. 23.
    Hagg O, Lundberg BJ. Aspects of prognostic factors in comminuted and dislocated proximal humerus fractures. In: Bateman JE, Welsh RP, editors. Surgery of the shoulder. Philadelphia: Decker; 1984.Google Scholar
  24. 24.
    Besch L, Daniels-Wredenhagen M, Mueller M, Varoga D, Hilgert RE, Seekamp A. Hemiarthroplasty of the shoulder after four part fracture of the humeral head: a long term analysis of 34 cases. J Trauma. 2009;66(1):211–4.CrossRefGoogle Scholar
  25. 25.
    Mansat P, Guity MR, Bellumore Y, Mansat M. Shoulder arthroplasty for late sequelae of proximal humeral fractures. J Shoulder Elb Surg. 2004;13:305–12.CrossRefGoogle Scholar
  26. 26.
    Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal humeral fractures with Polarus nail fixation. J Shoulder Elb Surg. 2004;13:191–5.CrossRefGoogle Scholar
  27. 27.
    Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with the Polarus nail. J Shoulder Elb Surg. 2001;10:7–10.CrossRefGoogle Scholar
  28. 28.
    Cuny C, Scarlat MM, Irrazi M, et al. The telegraph nail for proximal humeral fractures: a prospective four year study. J Shoulder Elb Surg. 2008;17(4):539–45.CrossRefGoogle Scholar
  29. 29.
    Giannoudis PV, Xypnitos FN, Dimitriou R, Manidakis N, Hackney R. Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature. J Orthop Surg Res. 2012;19(7):1749–99.Google Scholar
  30. 30.
    Neer CSII. Displaced proximal humeral fractures. Part II. Treatment of three part and four part displacement. J Bone Joint Surg Am. 1970;52A:1090–103.CrossRefGoogle Scholar
  31. 31.
    Neer CS. Indications for replacement of the proximal humeral articulation. Am J Surg. 1955;89:901–7.CrossRefGoogle Scholar
  32. 32.
    Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008;90(11):1407–13.CrossRefGoogle Scholar
  33. 33.
    Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br. 2004;86:848–55.CrossRefGoogle Scholar
  34. 34.
    Dines DM, Warren RF. Modular shoulder hemiarthroplasty for acute fractures. Surgical considerations. Clin Orthop Relat Res. 1994;307:18–26.Google Scholar
  35. 35.
    Gronhagen CM, Abbaszadegan H, Revay SA, Adolphson PY. Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: a study of 46 patients followed up for an average of 4.4 years. J Shoulder Elb Surg. 2007;16:766–73.CrossRefGoogle Scholar
  36. 36.
    Sirveauz F, Favard L, Oudet D, Huguet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicenter study of 80 shoulders. J Bone Joint Surg Br. 2004;86:388–95.CrossRefGoogle Scholar
  37. 37.
    Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the treatment of three and four part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow up. J Bone Joint Surg Br. 2007;89:516–20.CrossRefGoogle Scholar
  38. 38.
    Cazeneuve JF, Cristofari DJ. The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly. J Bone Joint Surg Br. 2010;92:535–9.CrossRefGoogle Scholar
  39. 39.
    Klein M, Juschka M, Hinkenjann B, Scherger B, Ostermann PA. Treatment of comminuted fractures of the proximal humerus in elderly patients with the delta III reverse shoulder prosthesis. J Orthop Trauma. 2008;22(10):698–704.CrossRefGoogle Scholar
  40. 40.
    Chen L, Xing F, Effectiveness XZ. Safety of interventions for treating adults with displaced proximal humeral fracture: a network meta-analysis and systematic review. PLoS One. 2016;11(11):e0166801.  https://doi.org/10.1371/journal.pone.0166801. eCollection 2016. ReviewCrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Zyto K, Ahrengart L, Sperber A, Törnkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br. 1997;79(3):412–7.CrossRefGoogle Scholar
  42. 42.
    Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am. 2013;95(18):1701–8.CrossRefGoogle Scholar
  43. 43.
    Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am. 2013;95(22):2050–5.  https://doi.org/10.2106/JBJS.L.01637.CrossRefPubMedGoogle Scholar
  44. 44.
    Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elb Surg. 2013;22(1):32–7.  https://doi.org/10.1016/j.jse.2012.03.006. Epub 2012 May 29CrossRefGoogle Scholar
  45. 45.
    Chalmers PN, Slikker W 3rd, Mall NA, Gupta AK, Rahman Z, Enriquez D, Nicholson GP. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elb Surg. 2014;23(2):197–204.  https://doi.org/10.1016/j.jse.2013.07.044. Epub 2013 Sep 27CrossRefGoogle Scholar
  46. 46.
    Gerber C, Pennington SD, Nyffeler RW. Reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2009;17:284–95.CrossRefGoogle Scholar
  47. 47.
    Affonso J, Nicholson GP, Frankle MA, Walch G, Gerber C, Garzon- Muvdi J, et al. Complications of the reverse prosthesis: prevention and treatment. Instr Course Lect. 2012;61:157–68.PubMedGoogle Scholar
  48. 48.
    Cazeneuve JF, Cristofari D-J. Delta III reverse shoulder arthroplasty: radiological outcome for acute complex fractures of the proximal humerus in elderly patients. Orthop Traumatol Surg Res. 2009;95:325–9.  https://doi.org/10.1016/j.otsr.2009.03.018.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Paolo Paladini
    • 1
  • Giovanni Merolla
    • 1
  • Carlo Alberto Augusti
    • 1
  • Giuseppe Porcellini
    • 2
  1. 1.Unit of Shoulder and Elbow SurgeryCervesi HospitalCattolicaItaly
  2. 2.Orthopaedic Department, Policlinico di ModenaUniversity of Modena and Reggio EmiliaModenaItaly

Personalised recommendations