Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: A retrospective study in 42 patients

Injury, Int. J. Care Injured 40 (2009) 1336–1341

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Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: A retrospective study in 42 patients Erdinc¸ Esen a,*, Yunus Dog˘ramacı b, Serap Gu¨ltekin c, Mehmet Ali Deveci a, Fatih Suluova a, Ulunay Kanatlı a, Selc¸uk Bo¨lu¨kbas¸ı a a b c

Gazi University, Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara, Turkey Mustafa Kemal University, Faculty of Medicine, Department of Orthopedics and Traumatology, Hatay, Turkey Gazi University, Faculty of Medicine, Department of Radiology, Ankara, Turkey

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 15 June 2009

Aim: Our study reports long-term results and factors related to patient satisfaction in the case of primary hemiarthroplasty for humeral proximal end fractures. Patients and methods: We retrospectively evaluated 42 patients with humeral proximal end fractures who underwent primary hemiarthroplasty in our clinic from February 1994 to March 2004. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9  5.57 years (age range: 59–81 years). The mean follow-up period was 78.8  26.6 months (range: 48–118 months). We evaluated the following parameters: fracture type according to the Neer classification, the time interval between the fracture and the operation, postoperative radiological examination, the Neer outcome assessment criteria for patient satisfaction and functions, according to the Constant and Murley Scoring (CMS) system. Results: We found good-to-excellent outcomes in 36 (85.7%) and poor outcome in six (14.3%) patients according to the Neer criteria. The average values for CMS score, anterior elevation and external rotation were 73.59  17.95 (25–94), 121.30  42.998 (range: 30–1708) and 308 (range: 0–808), respectively. The patients who had been operated in the early period (within 2 weeks) had better functional outcomes (p < 0.001) and had significant pain relief. There was a strong positive correlation between the humeral offset (distance between the head and the tuberosities) and the degree of elevation (r = 0.872, p < 0.001). There was a strong negative correlation between the height of the humeral head and the degree of elevation (r = 0.853, p < 0.001). Conclusion: In humeral proximal end fractures, primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and long-term regular rehabilitation programme are important factors contributing to increased patient satisfaction. ß 2009 Elsevier Ltd. All rights reserved.

Keywords: Hemiarthroplasty Humeral proximal end fracture Shoulder pain

Hemiarthroplasty for the treatment of proximal humeral fractures provides good-to-excellent pain relief in 73–97% of patients. Patients are usually satisfied with this procedure and the reported satisfaction rates are between 70% and 92% of the patients in the literature.6–9,11,13,16,18,24,25,27,31 Although hemiarthroplasty is associated with reliable relief of pain as well as a high rate of patient satisfaction, the functional outcomes can vary. This variability is related to intra-operative and postoperative complications (e.g., infection, neurological injury, intra-operative fracture, instability, mal-union and non-union of tuberculum, rotator cuff tear, malpositioning of the components, heterotopic ossification, glenoid erosion and stiffness). These complications are related to the technical errors during surgery, the timing of surgery, the nature of

* Corresponding author. Tel.: +90 312 2025529; fax: +90 312 2129008. E-mail address: [email protected] (E. Esen). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.06.019

patient population, experience of the surgeons and the different methods used for the assessment of results.6–11,13,16,18,24,25,27,31 The purpose of this study is to evaluate the long-term results of patients who underwent primary hemiarthroplasty for the treatment of proximal humeral fractures and for the determination of the risk factors that affect clinical outcome. Patients and methods In this retrospective study, between February 1994 and March 2004, we evaluated 42 elderly patients with humeral proximal end fractures, who had undergone primary hemiarthroplasty. These patients had detailed operative records. The inclusion criteria were patients with non-pathologic fractures who had a complete preoperative evaluation. We included the patients who had undergone at least 48 months of follow-up (range: 48–118 months, mean 78.8  26.6 months). The exclusion criteria were

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Table 1 Patient demographics data. P

Age

Time to surgery (day)

Pain

Elevation degree

Satisfactory

Acromio-humeral distance (mm)

Humeral offset

Humeral head height

Constant–Murley score

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

67 71 72 80 79 68 59 64 63 73 70 61 59 61 73 71 81 67 66 71 75 70 68 73 74 70 65 61 70 74 67 62 72 71 66 68 69 73 63 74 74 61

5 8 2 21 5 3 7 2 8 6 2 5 10 3 19 4 21 6 3 20 22 4 7 4 3 26 4 9 13 6 12 4 12 11 4 9 3 5 11 10 12 9

0 0 0 1 0 0 0 0 0 0 0 0 0 0 2 0 2 0 0 2 0 1 0 0 0 2 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0

140 150 90 45 110 170 140 160 120 100 150 160 170 110 40 120 30 170 160 45 40 90 150 110 110 45 120 150 170 90 150 160 100 100 90 150 170 120 120 90 110 150

Excellent Excellent Good Poor Good Excellent Excellent Excellent Good Good Excellent Excellent Excellent Good Poor Good Poor Excellent Excellent Poor Poor Good Excellent Good Good Poor Good Excellent Excellent Good Excellent Excellent Good Good Good Excellent Excellent Good Good Good Good Excellent

24 20 14 5 10 16 14 18 12 10 16 18 21 11 7 12 9 16 19 9 7 14 21 16 20 6 13 22 28 13 21 12 11 14 13 27 25 11 14 13 10 22

26 27 24 20 24 26 26 28 23 23 27 26 28 25 14 24 18 27 26 20 14 24 26 23 25 19 24 26 27 24 27 27 25 24 24 27 26 23 24 23 25 27

8 6 12 22 13 8 10 7 1 12 10 8 9 14 24 13 26 8 11 22 18 12 10 13 14 21 13 10 8 12 8 7 12 11 13 9 7 11 12 12 13 8

94 90 74 25 70 88 92 90 68 66 87 92 90 72 36 70 32 91 90 45 40 68 89 70 67 45 72 92 90 74 78 82 68 66 74 90 88 68 72 74 70 92

Complication

Tuberosity resorbtion

Hematoma

Axillary nerve injury I˙nfection + tuberosity resorbtion Tuberosity fixation insufficient

Tuberosity fixation insufficient Rejional Pain Syndrome

Tuberosity resorbtion Axillary nerve injury

P: patient, pain 0: no or little, 1: moderate, 2: severe.

patients with ipsilateral comminuted fracture, who had a previous history of trauma or a fracture or an operation in the same shoulder and patients with rotator cuff tear. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9  5.57 years (age range: 59–81 years) and the fracture involved the dominant arm in 64% (n = 27) of the patients (Table 1). Two surgeons (SB, UK), who had more than 10 years experience in shoulder surgery, were involved this study. According to the Neer classification,14 25 (60%) cases had fourpart fractures, seven (17%) had three-part fractures, six (14%) had three-part fractures with dislocation and four patients (9%) had head-splitting fractures (Fig. 1). The causes of the fracture were motor vehicle accidents in 19 patients and falls in 23 patients. The physical examinations revealed that four patients had axillary nerve injury, two patients had distal radius fracture, one had elbow dislocation and another had ipsilateral non-displaced fracture of the tibia as well. All patients declared that they could easily and actively raise their arms to an overhead level preoperatively. Surgical technique All the operations were performed by two surgeons (SB, UK) experienced in shoulder surgery. During the operation, intrave-

nous injection of 1 g cefazolin sodium was administered to all patients before skin incision, and the same medication was continued postoperatively. All the patients were placed in the beach-chair position. The standard delto-pectoral incision was made in all of them. The lesser and greater tuberosities were liberated. After the preparation of the humeral channel, two holes were drilled in the proximal humerus and 5/0 Ethibond (Ethicon Inc., USA) sutures were inserted. The humeral component was placed by using cement in the head position in appropriate retroversion. The posterior fin of the prosthesis was placed 1–1.5 cm posterior to the biceps groove to determine the position of the humeral head. On manually mixing the cement, the first-generation cementing technique was used. As the cement settled, Ethibond sutures in the humeral stem were moved so that lubrication was provided. Biomodular (Biomet, Warsaw, IN, USA) and Neer II (Hipokrat, Turkey) shoulder prostheses were used in 32 and 10 patients, respectively (Fig. 2). A 5/0 Ethibond (Ethicon Inc., USA) suture was used to stabilise the tuberosities. In all patients, the sutures were inserted into the tuberosity, prosthesis fin and the holes drilled in the humerus by an appropriate surgical technique. Therefore, the tuberosities, prosthesis and the humerus were meticulously stabilised to each other, both vertically and horizontally. Rotator cuff repair was undertaken using a 1/0 Ethibond (Ethicon Inc., USA). Velpeau

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Fig. 1. (A and B) 68-year-old patient with three-part fracture with dislocation of proximal humerus.

Fig. 2. (A and B) Postoperative true AP and axiller radiography shows the proximal humeral end prosthesis.

bandage was applied to all patients postoperatively (shoulder in internal rotation, neutral flexion and abduction and elbow at 908 flexion). Pendulum and passive exercises, including 908 passive elevation, were begun on the first postoperative day. Activeassisted exercises were begun at the second and third weeks. The velpeau bandage was taken off at the sixth week, and active and resistant exercises were started. Rehabilitation programmes (patient compliance towards treatment and physical rehabilitation programme, exercise performance) were conducted by an experienced physiotherapist for 6 months with weekly followup visits.

Anteroposterior, true anteroposterior (scapular anteroposterior), trans-scapular lateral and axillary radiographs were used for radiological assessment. The position of the prosthesis, the degree of formation of a radiolucent line around the humeral stem, the union status of the tuberosities, the distance between the external rim of greater tuberosity and the center of the prosthesis head (humeral offset), the distance between the highest part of the humeral head and upper part of greater tuberosity (head height) and the distance between the humeral head and the acromion (acromio-humeral distance) were measured. Statistics

Assessment criteria The clinical outcomes were assessed using the Neer criteria,20 Constant and Murley Scoring (CMS) system5 and degree of elevation. Postoperative follow-up examination was conducted by the same surgeons at 6 months and controlled examination yearly thereafter. Clinical satisfaction outcomes were classified as excellent, good and poor using the Neer criteria. The CMS system was used for functional scoring. The criteria for functional scoring were the intensity of pain, capability of doing daily activities, the degree of shoulder movement and muscle strength.

Correlations between parametric and non-parametric variables were assessed. Parametric variables included the head height, humeral offset and the degree of elevation. Non-parametric variables included the time of the operation and pain, satisfaction level and the CMS scores, problems of tuberosities and success rate, compliance with physiotherapy and the Neer satisfaction scoring. Data were analysed using the SPSS 11.5 Windows program (SPSS, Chicago, IL, USA). The difference between the groups was analysed using Mann–Whitney U and the Kruskal–Wallis nonparametric tests. The correlation between the groups was analysed

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using Pearson’s correlation and the coefficient tests. p values of lesser than 0.05 were considered to be statistically significant. Results According to the Neer criteria,20 36 shoulders (85.7%) had goodto-excellent outcomes and six (14.3%) had poor outcomes. At last visit, 34 patients had little or no pain, and four patients each had moderate and severe pain. The mean CM score16 was 73.59  17.95 (range: 25–94). During clinical examination, the mean anterior elevation was 121.30  42.998 (range: 30–1708) and external rotation was 308 (range: 0–808). In internal rotation, the level of the thumb level correlated with the L5 vertebra (abdomen–T10). Of the 42 patients, three had tuberosities resorption: due to infection in one and due to unknown reasons in the other two. Two patients had upward migration due to the insufficient fixation of tuberosities and underwent revision surgery during the first 6 months for debridement and repositioning. There was no significant relationship between gender and fracture type and postoperative range of motion (p > 0.05). There was an inverse relationship between age and the degree of elevation. Accompanying fractures and axillary nerve injuries were followed up conservatively without surgical intervention. All axillary nerve injuries resolved completely in 6 months. The mean period for follow-up was 78.8  26.6 months (range: 48–118 months). The mean time between trauma and operation was 8.5  6.2 days (range: 2–26 days). During follow-up with true anteroposterior roenthgenograms, 38 patients had a mean humeral offset of 24.23  3.18 mm (the normal distance between greater tuberosity and humeral head is 14– 28 mm). In patients with humeral offset of 22 mm and below, the outcome using the Neer criteria was poor and in patients with humeral offset of 24 mm, the outcome was good to excellent. There was a strong positive correlation between humeral offset and the degree of elevation (r = 0.872, p < 0.001) (Fig. 3). The mean humeral height was 11.85  5.06 mm. In cases with 13 mm humeral height (i.e., too distant placement of tuberosities) the level of satisfaction was lower. There was a strong negative correlation between humeral height and the degree of elevation (r = 0.853, p < 0.001) (Fig. 4). The acromio-humeral distance was measured as an indicator of sufficient and meticulous rotator cuff repair. There was a strong positive correlation between the acromio-humeral distance and the degree of elevation (r = 0.792, p < 0.001) (Fig. 5).

There was a significant relationship between compliance with physiotherapy and the level of satisfaction (p < 0.001). The level of satisfaction was higher in patients with better compliance to rehabilitation programme in the presence of an expert physiotherapist. During the evaluation of radiographs, stage 1–2 periprosthetic radiolucency was observed in nine patients (30%). Although there were mild-to-moderate degenerative changes at the glenoid in 15 patients (50%), there was no significant relationship between these degenerative changes and the level of pain or functional outcomes. There was resorption of tuberosities in three cases and the need for repositioning to a superior position in two cases due to insufficient fixation. The union of tuberosities was proper in 37 patients (80%). In patients with proper union in the right position, CMS showed strong positive correlation with the degree of elevation and the level of satisfaction (r = 0.939, p < 0.001) (Fig. 6). Short- and long-term postoperative complications were observed in nine of 42 patients (21.4%). Postoperative axillary nerve injury occurred in two patients, and they recovered completely in 1 year. Superior migration of the tuberosities was observed in two patients due to insufficient fixation. They were re-

Fig. 3. The correlation between humeral offset and elevation degree.

Fig. 5. The correlation between acromio-humeral distance and elevation degree.

Fig. 4. The correlation between humeral height and elevation degree.

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Fig. 6. The correlation between Constant–Murley score and elevation degree.

operated for debridement and fixation. One patient suffered from reflex sympathetic dystrophy in the postoperative period, and the patient recovered with appropriate physiotherapy and medical treatment. One patient developed postoperative haematoma and it was drained in the early period. There was moderate-level resorption of the tuberosities in three patients. Six patients were old and had systemic diseases, such as diabetes, and resulted in poor outcome. No serious complications such as loosening of prosthesis, deep and wide infection or severe resorption of the tuberosities were observed. The shoulder and prosthesis were stable in all patients. Radiographic findings of loosening were not observed in any patients. Except three patients with resorption, none of patients had non-union of tuberosities. Discussion In this study, we found long-term satisfactory results of primary hemiarthroplasty in proximal humeral fractures. These satisfactory results were related to the anatomic reconstruction of bone and soft tissues of the shoulder joint, experience of the surgeon, detailed surgical planning and meticulous surgical technique and long-term regular rehabilitation programme. However, the limitations to our study need to be considered. First, it was a retrospective study and thus it lacks the value of prospective one. Second, different kinds of humeral prosthesis were used in this study. Finally, there was no control group who had undergone open reduction and internal fixation. The experience of the surgeon and long-term follow-up are very important in primary shoulder hemiarthroplasty for the treatment of humeral head fractures. There are many cases reported in the literature2,4,12,13,19,28,30,31 that were operated by general orthopaedic surgeons who were not specialised in shoulder surgery. In these studies, patients were followed up in a short period of time. This leads to a wide variation in results in the literature. According to the studies reported, the rate of tuberosities union is related to the experience of the surgeon and, therefore, it is important that these operations should be performed by orthopaedic surgeons specialised in shoulder surgery.1,3,6,8,11,17,23 In our study, all operations were performed by two surgeons dealing specifically with shoulder surgery (SB, UK). Tuberosities and rotator cuff failures may lead to persisting pain and non-compliance with the rehabilitation programmes. It has been reported that delaying the rehabilitation programme until

tuberosities union is radiologically confirmed in elder patients would be more convenient.1,8,11,21,23,26 The correct relation between the head and the tuberosities, avoiding superior migration of tuberosities and meticulous fixation of tuberosities to each other and to the humeral stem are important factors for providing good rotator cuff functions. In our study, the outcome using the Neer criteria was poor in patients with humeral offset of 22 mm and below, and it was good to excellent in patients with humeral offset of 24 mm. Arthroplasty in patients with the failure of previous internal fixation and with mal-union is technically more difficult and has a low success and a high complication rate.1–4,6,8,13,15,17,19,23,31 Secondary hemiarthroplasty after ORIF displayed more unfavourable outcomes.1,4,6,8,23,25,29,31 The reason may be due to the high incidence of soft-tissue contractures, rotator cuff injury, nonunion, mal-union and the infections caused by previous surgery.1– 4,6,8,13,17,19,23,31 In our study, all patients underwent primary hemiarthroplasty. There were no patients with secondary hemiarthroplasty. It was reported that early hemiarthroplasty for the treatment of humeral head fractures had better clinical outcomes.1,2,6,8,13,22,23 The shorter the period, the higher the success rate. A surgical intervention in the first 7 days or 2 weeks is ideal, as claimed by some authors. In our study, the mean time between trauma and operation was 8.5  6.2 days (range: 2–26 days). Due to this, shoulder pain improved faster, the compliance towards rehabilitation was better and functional outcomes were more favourable. Conclusion Primary hemiarthroplasty is an acceptable and often preferred method of treatment of proximal humeral fractures. Long-term regular rehabilitation programme, the anatomic reconstruction of bone and soft tissues of the shoulder joint, experience of the surgeon and detailed surgical planning and meticulous surgical technique are important factors to have satisfied clinical outcomes. References ˜ a SA, Sperling JW, Cofield RH. Shoulder hemiarthroplasty for acute 1. Antun fractures of the proximal humerus: a minimum five-year follow-up. J Shoulder Elbow Surg 2008;17(March–April (2)):202–9. 2. Becker R, Pap G, Machner A, Neumann WH. Strength and motion after hemiartroplasty in displaced four-fragment fracture of the proximal humerus: 27 patients followed for 1–6 years. Acta Orthop Scand 2002;73(January (1)):44–9. 3. Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole` D. Tuberosity malposition and migration: reason for poor outcomes after hemiarthroplasty for displaced fractures of proximal humerus. J Shoulder Elbow Surg 2002;11(September–October (5)):401–12. 4. Bosch U, Skutek M, Fremerey RW, Tscherne H. Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus. J Shoulder Elbow Surg 1998;7(September–October (5)):479–84. 5. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214(January):160–4. 6. Compito CA, Self EB, Bigliani LU. Arthroplasty and acute shoulder trauma. Reasons for success and failure. Clin Orthop 1994;307(October):27–36. 7. Demirhan M, Akpinar S, Atalar AC, et al. Primary replacement of the humeral head in iatrogenically displaced fracture-dislocations of the shoulder: a report about six cases. Injury 1998;29(September (7)):525–8. 8. Demirhan M, Kilicoglu O, Altinal L, Eralp L, Akalin Y. Prognostic factors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma 2003;17(March (3)):181–8 [discussion 188–9]. 9. Dimakopoulos P, Potamitis N, Lambiris E. Hemiarthroplasty in the treatment of comminuted intraarticular fractures of the proximal humerus. Clin Orthop Relat Res 1997;341(August):7–11. 10. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am 1990;72(December (10)):1486–94. 11. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4(March–April (2)):81–6. 12. Hartsock LA, Estes WJ, Murray CA, Friedman RJ. Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29(July (3)):467–75.

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