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Shoulder arthroplasty for late sequelae of proximal humeral fractures
Shoulder arthroplasty for late sequelae of proximal humeral fractures Pierre Mansat, MD, PhD,a Mohamad R. Guity, MD,b Yves Bellumore, MD,a and Michel Mansat, MD,a Toulouse, France, and Tehran, Iran
Twenty-eight patients with sequelae of proximal humeral fractures were treated with shoulder arthroplasty and were reviewed with a mean follow-up of 47 months. There were 8 malunions, 7 osteonecrosis, and 2 nonunions of the proximal humerus. Degenerative joint disease without any distortion of the tuberosities had developed in 11. We performed 8 total shoulder arthroplasties and 20 hemiarthroplasties. On the basis of the Neer criteria, the results were satisfactory in only 64%. Fifteen patients had superior migration of the implant. One patient had to be reoperated on because of deep infection. The prognosis was influenced positively by the integrity of the rotator cuff at surgery, whereas the need for greater tuberosity osteotomy worsened the final result. The data suggest that malunion of the greater tuberosity can be tolerated if it does not compromise acceptable positioning of the humeral component. However, if there is a malunion of the greater tuberosity with major displacement, an osteotomy must be performed, with unpredictable results. (J Shoulder Elbow Surg 2004;13:305–12.)
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he treatment of complex humeral fractures or fracture-dislocations presents several challenges. Late complications such as malunion, avascular necrosis, or nonunion are frequent and often lead to articular incongruence.2,9,19 Patients can be severely handicapped, presenting with considerable pain, stiffness, and important functional impairment. Stiff shoulders with distorted proximal humeri, softtissue damage, a scarred deltoid, and rotator cuff tears make shoulder arthroplasty a challenging procedure, often with unpredictable results and a high risk of complications.5,22 From the Service d’Orthope´die-Traumatologie, Centre Ho ˆ spitalier Universitaire de Toulouse, Toulouse,a and the Department of Orthopedics, Imam University Hospital, Tehran.b Reprint requests: Pierre Mansat, MD, PhD, Service d’Orthope´dieTraumatologie, Centre Ho ˆ spitalier Universitaire de Toulouse, Purpan, Place du Dr Baylac, 31059, Toulouse, France (E-mail: [email protected]). Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.01.020
The overall results of patients with old trauma are inferior to the results currently obtained in patients with primary osteoarthritis or with recent 4-part fractures who are treated initially with humeral head replacement.7,15,17 Very little has been written on the results of shoulder arthroplasty for management of sequelae of proximal humeral fractures.2– 4,9 –12,17,19-21 The purpose of this study was to report our experience with shoulder arthroplasty in the context of old trauma. Preoperative planning, surgical technique, clinical and radiographic results, and prognostic factors are discussed. PATIENTS AND METHODS From 1984 through 1997, 49 patients underwent shoulder arthroplasty for the treatment of posttraumatic arthritis. Only patients with sequelae of proximal humeral head fractures were included in this study. Three patients (five shoulders) who had a shoulder arthroplasty for sequelae of proximal humeral head fractures were lost to follow-up. Twenty-eight patients with a minimum of 2 years’ follow-up were available for the study and were reviewed. There were 9 men and 19 women. The dominant side was involved in 15 cases. The mean age of patients at surgery was 61 years (range, 36-79 years). Two patients performed heavy labor, five performed manual labor, eight were sedentary, and thirteen were retired. The initial trauma was a 3-part proximal humeral fracture in 10 and a 4-part fracture in 7. For the 11 other patients, the nature of the fracture was unknown or was classified as a complex fracture. These fractures were managed conservatively in 11 cases and surgically in 17; a closed reduction with intramedullary pinning14 was performed in 9, an open reduction with internal fixation in 6, and the procedure was unknown for 2. Late sequelae of the proximal humeral fractures were incongruence of the glenohumeral joint without any distortion of the proximal humerus in 11, secondary osteonecrosis in 7, osteoarthritis with nonunion in 2, and osteoarthritis with malunion of the proximal humerus in 8. The delay between the initial fracture and shoulder arthroplasty averaged 96 months (range, 12-360 months). The duration of the symptoms before the shoulder arthroplasty procedure averaged 32 months (range, 6-120 months). Patients were evaluated postoperatively by the criteria of Constant and Murley.8 Strength had not been measured before surgery and was measured postoperatively in only 14 patients. The Neer score7,17 was also used for further evaluation of the results at latest follow-up. The criteria for
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considering a result as excellent were as follows: little or no pain, normal use of the arm, anterior elevation greater than 130°, external rotation greater than 90% of that of the contralateral side, and strength within normal range. Satisfactory results included those cases in which moderate pain persisted but the arm could be used almost normally, anterior elevation in the range of 90° to 135°, and external rotation that is 50% of that of the opposite side. Unsatisfactory results comprised those cases not fulfilling the above criteria. Subjective pain evaluation was performed with a visual analog score, in which the patient gives a number from 0 to 15 according to the severity of his or her pain (0 indicates maximum pain and 15 indicates no pain). According to the Constant criteria, the patients’ level of activity and functional range of motion of the affected shoulder were evaluated. Determination of the level of activity was based on such factors as professional handicap, disability in performing daily activities, disturbance of sleep, and the level that could be reached by the hand. Ranges of active anterior elevation and active external rotation were recorded in degrees. Range of internal rotation was measured based on the ability of the thumb to reach vertebral segments. Preoperative, initial postoperative, and most recent radiographs were evaluated for all patients. Four projections were used for analysis: an axillary view, an anterior-posterior view with external rotation of the humerus, an anteriorposterior view with internal rotation of the humerus, and an anterior-posterior view with neutral rotation of the humerus. Of 26 patients, 20 had a computed tomography scan evaluation before surgery to show the incongruence between the humeral head and the glenoid, to identify a possible malunion, and to estimate the bone stock quality and quantity. In 6, a 3-dimensional reconstruction had helped to demonstrate such findings better and also had allowed determination of the anatomic axis of the humerus and the degree of humeral and glenoid version.16 The most recent radiographs were reviewed to determine the presence of periprosthetic lucency, the position of the implants, and the presence of periprosthetic ossification. Glenoid wear was evaluated as concentric or eccentric on the axillary view.13 In 18 cases the glenoid was considered to be concentric (type A according to the classification of Badet et al1), whereas it was eccentric in 10 cases (type B1 according to the classification of Badet et al).
Surgical technique Our technique was similar to that originally described by Neer.18 A total shoulder arthroplasty was performed in 8 cases and a hemiarthroplasty in 20 cases. A Neer II prosthesis (3M, St Paul, MN) was used for 15 patients (7 total shoulder arthroplasties and 8 hemiarthroplasties), and a modular shoulder arthroplasty (3M) was used in the other 13 patients (1 total shoulder arthroplasty and 12 hemiarthroplasties). The humeral component was always cemented. The glenoid component was an all-polyethylene keel-type implant and was also cemented in all cases. A deltopectoral approach was used in all cases except one, in which the existing superior incision scar was used. The deltoid muscle was found to be normal in 26 cases and atrophic in 2. The subscapularis tendon was normal in 17
J Shoulder Elbow Surg May/June 2004
patients and fibrotic in 11. To restore a functional range of external rotation, we had to release the joint capsule from around the glenoid rim and the subscapularis from the scapular neck in 17 patients. In 3 cases a Z-lengthening of the subscapularis tendon was done for the same purpose. The other rotator cuff tendons were normal in 20 patients and torn in 8 (5 isolated supraspinatus ruptures and 3 supraspinatus and infraspinatus lesions). The rotator cuff tear was repaired in 3 cases with isolated supraspinatus lesions, whereas it was not possible to repair it in 1 case with an isolated supraspinatus lesion with malunion of the greater tuberosity and in the 3 cases with combined posterosuperior rotator cuff tears. In another patient, a local flap of the subscapularis muscle was used to replace the defect of the supraspinatus.6 The joint capsule was always incised together with the subscapularis. The biceps tendon was normal in 18 cases, showed pathologic changes in 9 (frayed or inflamed), and was ruptured in 1. A tenodesis was performed for 6 frayed biceps tendons. An osteotomy of the tuberosities was done in 3 cases with malunion to better reattach the tuberosities around the prosthesis, with care taken to leave enough bone attached to the rotator cuff to allow solid fixation. Fixation of the tuberosities was performed with two different types of No. 5 nonabsorbable sutures: horizontal transverse intertuberosity sutures and vertical diaphyseal tuberosity (tension-band system) sutures. Before tuberosity reposition, cancellous autografts were put into the proximal humeral space, filling the spaces between the implant and the tuberosities. The tuberosities were tightened to the lateral fins of the prosthesis, and the tuberosities were then fixed together and to the humeral diaphysis. The rotator cuff interval was then closed with separate sutures. The long head of the biceps was systematically fixed at the intertuberosity interval. The arm was immobilized by means of a sling in internal rotation with the elbow at the side for 6 weeks. In the 3 cases with osteotomy of the greater tuberosity, an abduction splint was used for 6 weeks. On the third postoperative day, a rehabilitation program was started. This program followed the principles described by Neer.18 The time to begin active exercises depended on such factors as the initial etiology, whether an osteotomy of the tuberosity had been performed, and the quality of the rotator cuff. After a mean of 8 days of hospitalization, rehabilitation was continued in a specialized center in 25 cases and 3 patients followed their program with the help of a physiotherapist. The mean stay in the specialized center was 45 days. The mean time of rehabilitation was 6.7 months. Analysis of the data was done with statistical software (StatisticS, Toulouse, France), which allowed analysis of each variable separately and their interrelationship to be studied. A simple regression test was used to define the differences between the preoperative and postoperative values of the same variable. The correlation of each variable with all of the other variables was defined by the simple regression test or Student test.
RESULTS The final results were evaluated after a mean follow-up of 47 months (range, 24-158 months). According to the Neer rating system,17 an excellent
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Figure 1 Radiographic outcome of a 4-part humeral fracture impacted in valgus treated surgically in a 71-year-old patient. A, Anterior-posterior view of the initial fracture. B, Anterior-posterior view of the same shoulder after surgical treatment. C, Two years later, the shoulder developed a malunion of the proximal humerus with humeral head necrosis. D, A humeral head replacement was performed, and at 5 years’ follow-up, the patient had an excellent result according to the Neer rating system, with an adjusted Constant score of 99%.
result was obtained in 7 cases, a satisfactory result in 11, and an unsatisfactory result in 10. Nine patients were very satisfied with their surgery, twelve were
satisfied, and five found very little or no improvement. Two patients considered their symptoms to be worse than before surgery (Figure 1).
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Table I Postoperative assessment of humeral component positioning Radiographic measurement
Results (n ⴝ 28)
Distance Acromiohumeral distance Lateral humeral offset Greater tuberosity lever arm % of diaphyseal filling* Stem positioning†
6.7 mm 7 mm 24.3 mm 8.5 mm 49% –0.85°
*Calculated by dividing the stem width by the inner diaphysis width. If less than 0; the stem is in varus; 0° indicates the stem is normally positioned; if greater than 0°, the stem is in valgus. †
Clinical results
Clinical results were evaluated by the Constant criteria. Postoperatively, 24 patients (85%) had no or very slight pain. The pain score increased from a mean of 1.8 points (range, 0-10 points) to 11 points (range, 5-15 points) (P ⬍ .001). With regard to the activity level, the postoperative mean score increased significantly from 6.2 points (range, 4-10 points) to 14 points (range, 4-20 points) (P ⬍ .001). Fourteen patients were able to use their arms at shoulder level, and seven could use them above this level. Nine patients did not have any sleep disturbance related to the operated shoulder, and this discomfort was minimum for eight. Postoperatively, the mean score for mobility increased from 11 points (range, 4-16 points) to 23 points (range, 2-40 points) (P ⬍ .001). Active anterior elevation improved from a mean of 71° (range, 30°90°) to 107° (range, 40°-180°) (P ⬍ .01). External rotation measured in the standing position increased from a mean of ⫺8° (range, ⫺60° to 20°) to 20° (range, ⫺15° to 70°) (P ⬍ .01). Finally, range of active internal rotation increased from the ability of the thumb to reach the sacrum (range, greater trochanter to the first lumbar vertebral body) to the third lumbar vertebral body (range, trochanter to T7). Strength measured by a dynamometer for 14 patients was estimated at a mean value of 5.2 kg (range, 0-14.6 kg). Finally, the postoperative Constant score, calculated for only 14 patients who had measurement of the muscular force, was equal to 54 points (range, 17-83.6 points). With adjustment by age and sex, it was equal to a mean of 72% (range, 24%-117%). Radiographic analysis
Postoperative radiographs were available for all patients at the most recent follow-up. Periprosthetic ossification was present in 11 cases. It was minimal in 6 cases, predominant at the humeral side in 3, and near the glenoid in 2. No correlation was found
Figure 2 Illustration of humeral component positioning. GTLA, Greater tuberosity lever arm; D, distance; LHO, lateral humeral offset.
between the presence of ossifications and the final results. Correct positioning of the implants was assessed by studying various parameters on the anterior-posterior view with the humerus in neutral rotation (Table I and Figure 2). Nineteen humeral implants were normally positioned, four were found in valgus, and five were in varus. The mean vertical distance between the superior pole of the humeral implant and the superolateral corner of the greater tuberosity was 6.7 mm. In 3 cases the greater tuberosity was above the line drawn at the superior pole of the implant head perpendicular to the humeral axis. These 3 patients had excellent, satisfactory, and unsatisfactory results, respectively. In our series the position of the greater tuberosity was not found to affect the final results (P ⬎ .05). The acromiohumeral distance (AHD) was 7 mm on average (range, 0-13 mm). Fifteen patients had an AHD less than 8 mm. This distance measurement was correlated with postoperative activity (P ⬍ .01), postoperative mobility (P ⬍ .05), and postoperative anterior elevation (P ⬍ .01). The lateral humeral offset was 24.3 mm on average (range, 21-28 mm). This parameter had no influence on the final results. The lever arm of the greater tuberosity had a mean value of 8.5 mm (range, 4-24 mm). Again, we could find no correlation between this factor and the final results. Periprosthetic lucent lines around the humeral component were found in 8 cases. They were incomplete and were seated essentially under the head. In 3 cases, lucent lines were also found around the glenoid implant. These were complete in 1 case surrounding all of the implants and were incomplete in 2 other cases. All of these lucent lines had a width less than or equal to 1 mm, without any progression. In our study we found no case of superior displacement of the glenoid component or loose implants.
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Table II Clinical result at follow-up according to etiology
Cases Pain (out of 15 points) Activity (out of 20 points) Mobility (out of 40 points) Active anterior elevation (°) External rotation (°) Internal rotation (vertebral level) Neer score (excellent and satisfactory) Adjusted Constant score*
Posttraumatic arthritis without distortion
Avascular necrosis
Posttraumatic arthritis and malunion
Posttraumatic arthritis and nonunion
11 12 15 27.5 120 25 6.5 9/11 (82%) 88% (n ⫽ 5)
7 11 14 22.5 108 29 5 4/7 (57%) 69% (n ⫽ 5)
8 9 12 18 91 8 5 4/8 (50%) 69% (n ⫽ 2)
2 7.5 11 16 95 15 3 1/2 (50%) 45% (n ⫽ 2)
Clinical results are expressed according to the Constant criteria.16 *Only 14 patients had a complete Constant score with strength measurement.
We had one complication in this study. One revision surgery was necessary because of a deep infection developing 2 years after the operation. No site of entry could be found, and revision consisted of removal of the implant and joint resection. The patients’ age did not affect the final results, but sex had a significant correlation with measured strength (P ⬍ .001) for the 14 patients tested. Neither the time interval from the initial trauma to surgery nor the duration of symptoms influenced the final results. The type of glenoid noted on preoperative radiographic evaluation (type A or type B11) had no influence on the final outcome. The most important factor for the final results was the integrity of the rotator cuff muscles at surgery. This correlation was significant for postoperative pain score (P ⬍ .01), postoperative activity level (P ⬍ .01), and postoperative mobility (anterior elevation and external rotation). A torn rotator cuff at surgery was correlated with the diminution of the AHD in the postoperative period (P ⬍ .05). An excellent or satisfactory result was obtained in 77% of the patients who had an intact rotator cuff at surgery compared with only 14% for patients with a rotator cuff tear. Subjectively, the patients without a cuff tear were more satisfied with the operation than those with cuff lesions (P ⬍ .01). Postoperatively, the value of the AHD was also correlated with the final results. An excellent or satisfactory result was obtained in 77% of the 13 patients with an AHD of at least 8 mm and in 53% of the 15 patients with an AHD of less than 8 mm. The etiology influenced the final results; better results were obtained in cases with posttraumatic arthritis without any distortion of the tuberosity position, as compared with the cases with osteoarthritis superimposed on the nonunion or malunion. Shoulder arthroplasty for osteoarthritis with malunion or nonunion of the proximal humerus had the least favorable results in our series (Table II). The type of prosthesis (monobloc or modular), as
well as hemiarthroplasty versus total shoulder arthroplasty, had no influence on the outcome (Figure 3). The type of treatment for the initial trauma (conservative versus surgical) also had no influence on the outcome. In this series, osteotomy of the greater tuberosity was performed in only 3 patients, whose final Constant score averaged 36%, and all had unsatisfactory results according to Neer’s criteria. DISCUSSION The management of late sequelae after fracture of the proximal humerus is one of the most challenging problems encountered in shoulder surgery. All bony and soft-tissue pathology must be addressed at the time of arthroplasty to ensure the best result possible. The surgeon has to deal with malunion or nonunion of the proximal humerus, displacement of the tuberosities, bone loss, rotator cuff tears, scarred deltoids, and associated soft-tissue contractures. In addition, many of these shoulders have already undergone surgery. The results of shoulder arthroplasties for old trauma are much less favorable than those of primary osteoarthritis or hemiarthroplasties performed for acute fractures.7,15,17 Few articles in the literature specifically address the results of arthroplasties for posttraumatic sequelae, and only short series of patients have been published (Table III). On the basis of a literature review, a satisfactory result may be expected in 15% to 72% of the cases, with pain relief in more than 85%. However, Frich et al10 found that pain relief was unpredictable. Motion was usually limited, with an active anterior elevation around 110° and an active external rotation around 20°. The results of our study reflected those in the literature, with 85% of the patients having no or slight pain, active anterior elevation improving from a mean of 71° to 107°, and external rotation increasing from a mean of ⫺8° to 20°. The complication rate is usually higher than that
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Figure 3 Radiographic outcome of a 3-part humeral fracture treated conservatively in a 57-year-old patient. A, Anterior-posterior view of the initial fracture. B, One year later, the shoulder developed an avascular necrosis of the proximal humerus. C, Postoperative radiograph at 13 years’ follow-up (158 months) of the shoulder treated by total shoulder arthroplasty. The patient had a satisfactory result according to the Neer rating system, with an adjusted Constant score of 70.5%.
for other etiologies.5,21 The percentage of complications varies from 20% to 48% depending on the series (Table III). The revision rate varies from 3.5% to 35% (Table III). Several factors seem to influence the final results.
Norris et al,19 reviewing the results of 23 cases treated with shoulder arthroplasty for late complications of 3- and 4-part humeral head fractures, emphasized the crucial role of the initial fracture treatment for the final results of arthroplasty; the patients who
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Table III Review of literature reporting results of posttraumatic arthritis treated by shoulder arthroplasty
Author Neer et al17 (1982) Tanner and Cofield21 (1983) Huten and Duparc12 (1986) Frich et al10 (1991) Habermeyer and Schweiberer11 (1992) Dines et al9 (1993) Norris et al19 (1995) Postel et al20 (1995) Bosch et al4 (1998) Beredjiklian et al2 (1998) Boileau et al3 (2001) Current series
Cases
35
28
HHR vs TSA
0/35
28/0
Postoperative GT Satisfactory No or slight motion (AE/ ER) (°) osteotomy results (%) pain (%)
Activity at or above shoulder Complications Revision level (%) (%) (%)
NA
56
NA
NA
NA
NA
NA
NA
NA
89
112/42
NA
43
7
22
5/17
5
22
80
NA
27
NA
NA
27
4/23
NA
15
Unpredictable
NA
NA
26
NA
18
7/11
NA
32
NA
NA
NA
NA
NA
12
70
70
110/31
75
20
10
12
NA
95
92/27
53
48
21
9
19
61
92/22
55
12.5
12.5
20
14/6
23
6/17
48
19/39
14
14/0
NA
NA
NA
60/18
14
NA
NA
24
11/13
13
72
80
107/NA
83
36
34
71 28
46/25 20/8
20 3
42 64
NA 85
102/34 107/20
NA 75
27 3.5
5.6 3.5
HHR, Humeral head replacement; TSA, total shoulder arthroplasty; GT, greater tuberosity; AE, active anterior elevation; ER, active external rotation; NA, not applicable.
had been managed conservatively had a better result than those with initial surgical treatment. We could not show any statistical difference in our study regarding the initial treatment. Dines et al,9 in a more recent study of 20 cases of modular prosthesis, showed a better result for hemiarthroplasty, with a final score of 79.7 out of 100 with the Hospital for Special Surgery scoring system, in contrast to total shoulder replacement, which had a final score of 72 out of 100. In our series we have not found any statistical difference either between the results of hemiarthroplasty and total shoulder arthroplasty or between the results obtained with the monobloc implant (Neer II) versus the modular implant. More than the initial treatment of the fracture or the type of shoulder arthroplasty used, the type of sequelae seems to be one of the most important factors influencing the final results. In the study by Dines et al,9 for posttraumatic arthritis with avascular necrosis, a final score of 87.3 was achieved, whereas a score of 84.1 was obtained for posttraumatic arthritis with nonunion, 72 for humeral head defect, and 69.8 for malunion. For Neer et al,17 the outcome was better for post-dislocation arthropathy, with excellent results
in 76%, whereas 45% of those with post-fracture arthritis achieved excellent results. Recently, Boileau et al3 analyzed the results of shoulder arthroplasties for the treatment of the sequelae of proximal humeral fractures. Sequelae were divided into two categories; category 1 included intracapsular/impacted fracture sequelae (associated with both cephalic collapse or necrosis and chronic dislocation or fracture-dislocation), and category 2 included extracapsular/disimpacted fracture sequelae (associated with both surgical neck nonunions and severe tuberosity malunions). In category 1, the joint could be reconstructed without a greater tuberosity osteotomy, whereas in category 2, a greater tuberosity osteotomy was often needed (17/22 cases) to perform shoulder arthroplasty. The adjusted Constant score was better for sequelae of proximal humeral fractures of category 1 (73%) than for sequelae of category 2 (58.5%). The authors concluded that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty in this context and that it must be avoided when possible, with the surgeon accepting the distorted proximal anatomy. In our series better results also were obtained for post-
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traumatic arthritis without any distortion of the tuberosities, with a satisfactory result obtained in 82% of the cases, compared with avascular necrosis, with a satisfactory result obtained in 57%; posttraumatic arthritis with nonunion, with a satisfactory result obtained in 50%; and posttraumatic arthritis with malunion, with a satisfactory result obtained in 50%. The adjusted Constant score was better for posttraumatic arthritis without any distortion of the tuberosities (88%) than for malunion and nonunion (69% and 45%, respectively). Osteotomy of the greater tuberosity was performed in only 3 patients, whose final Constant score averaged 36%, and all had unsatisfactory results according to Neer’s criteria. These results seemed to confirm the general feeling concerning the poor results obtained after greater tuberosity osteotomy. According to our study and to the literature, prognostic factors that seem to influence the final results negatively are as follows: advanced age,9 duration of symptoms,4,20 etiology,3,9,17 rotator cuff tear,21 osteotomy of the tuberosity,3,9,21 and use of hemiarthroplasty versus total shoulder arthroplasty.9 The length of the rehabilitation time seems to be a very important factor for the final result.4,21 Bosch et al4 stated that what seems to be more important for rehabilitation, however, is the cooperation and mental state of patients, rather than their age. Conclusions
Shoulder arthroplasty for management of posttraumatic complications of fracture of the proximal humerus is a technically demanding procedure with unpredictable results. The high rate of complications is often related to technical difficulties, a scarred deltoid, adhesions of rotator cuff tendons, and malunion of the tuberosities. Careful selection of patients and preoperative planning are essential elements that guarantee achievement of good results. Greater tuberosity osteotomy must be avoided when possible, even if there is a distorted proximal humerus. If there is no impingement because of the tuberosity malunion, the shoulder arthroplasty must be adapted to the proximal humerus. The postoperative rehabilitation program should be modified based on the surgical findings and the technique used. In this manner, certain possible secondary complications could be avoided, and the long-term results will be more favorable.
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REFERENCES
1. Badet R, Walch G, Boulahia A. L’examen tomodensitome´trique dans l’omarthrose centre´e primitive. Rev Rhum Ed Fr 1998;65: 203-10. 2. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am 1998;80:1484-97. 3. Boileau P, Trojani C, Walch G, et al. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 2001;10:299-308. 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; 7:479-84. 5. Cofield RH, Edgerton B. Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect 1990;39:449-62. 6. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982;154:66772. 7. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am 1984;66:899-906. 8. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160-4. 9. Dines DM, Warren RF, Altchek DW, Moeckel B. Posttraumatic changes of the proximal humerus: malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty. J Shoulder Elbow Surg 1993;2:11-21. 10. Frich LH, Sojbjerg JO, Sneppen O. Shoulder arthroplasty in complex acute and chronic proximal humeral fractures. Orthopedics 1991;9:949-54. 11. Habermeyer P, Schweiberer L. Corrective interventions subsequent to humeral head fractures. Orthopade 1992;21:148-57. 12. Huten D, Duparc J. Prosthetic arthroplasty in recent and old complex injuries of the shoulder [in French]. Rev Chir Orthop Reparatrice Appar Mot 1986;72:517-29. 13. Levine WN, Djurasovic M, Glasson JM, et al. Hemiarthroplasty for glenohumeral osteoarthritis: results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-54. 14. Mansat M, Bellumore Y, Mansat P. Four-part proximal humerus fractures. In: Fu FH, Ticker JB, Imhoff AB, editors. An atlas of shoulder surgery. London: Martin Dunitz Ltd; 1998. p. 251-8. 15. Mansat M, Blazy O, Mansat P. Omarthroses centre´es. Rev Chir Orthop Reparatrice Appar Mot 1995;81(Suppl II):106-8. 16. Mansat M, Fourcade D. Preoperative planning in shoulder prosthesis [in French]. Acta Orthop Belg 1995;61(Suppl I):73-8. 17. Neer CS II, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-37. 18. Neer CS II. Glenohumeral arthroplasty. In: Neer CS II, editor. Shoulder reconstruction. Philadelphia: Saunders; 1990. p. 143269. 19. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg 1995;4:271-80. 20. Postel JM, Tamames M, Lenoble E, Goutallier D. Les arthroses post-traumatiques. Rev Chir Orthop Reparatrice Appar Mot 1995;81(Suppl II):111-5. 21. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop 1983; 179:116-28. 22. Wirth M, Rockwood C. Current concepts review: complications of total shoulder replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-16.
Twenty-eight patients with sequelae of proximal humeral fractures were treated with shoulder arthroplasty and were reviewed with a mean follow-up of 47 months. There were 8 malunions, 7 osteonecrosis, and 2 nonunions of the proximal humerus. Degenerative joint disease without any distortion of the tuberosities had developed in 11. We performed 8 total shoulder arthroplasties and 20 hemiarthroplasties. On the basis of the Neer criteria, the results were satisfactory in only 64%. Fifteen patients had superior migration of the implant. One patient had to be reoperated on because of deep infection. The prognosis was influenced positively by the integrity of the rotator cuff at surgery, whereas the need for greater tuberosity osteotomy worsened the final result. The data suggest that malunion of the greater tuberosity can be tolerated if it does not compromise acceptable positioning of the humeral component. However, if there is a malunion of the greater tuberosity with major displacement, an osteotomy must be performed, with unpredictable results. (J Shoulder Elbow Surg 2004;13:305–12.)
T
he treatment of complex humeral fractures or fracture-dislocations presents several challenges. Late complications such as malunion, avascular necrosis, or nonunion are frequent and often lead to articular incongruence.2,9,19 Patients can be severely handicapped, presenting with considerable pain, stiffness, and important functional impairment. Stiff shoulders with distorted proximal humeri, softtissue damage, a scarred deltoid, and rotator cuff tears make shoulder arthroplasty a challenging procedure, often with unpredictable results and a high risk of complications.5,22 From the Service d’Orthope´die-Traumatologie, Centre Ho ˆ spitalier Universitaire de Toulouse, Toulouse,a and the Department of Orthopedics, Imam University Hospital, Tehran.b Reprint requests: Pierre Mansat, MD, PhD, Service d’Orthope´dieTraumatologie, Centre Ho ˆ spitalier Universitaire de Toulouse, Purpan, Place du Dr Baylac, 31059, Toulouse, France (E-mail: [email protected]). Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.01.020
The overall results of patients with old trauma are inferior to the results currently obtained in patients with primary osteoarthritis or with recent 4-part fractures who are treated initially with humeral head replacement.7,15,17 Very little has been written on the results of shoulder arthroplasty for management of sequelae of proximal humeral fractures.2– 4,9 –12,17,19-21 The purpose of this study was to report our experience with shoulder arthroplasty in the context of old trauma. Preoperative planning, surgical technique, clinical and radiographic results, and prognostic factors are discussed. PATIENTS AND METHODS From 1984 through 1997, 49 patients underwent shoulder arthroplasty for the treatment of posttraumatic arthritis. Only patients with sequelae of proximal humeral head fractures were included in this study. Three patients (five shoulders) who had a shoulder arthroplasty for sequelae of proximal humeral head fractures were lost to follow-up. Twenty-eight patients with a minimum of 2 years’ follow-up were available for the study and were reviewed. There were 9 men and 19 women. The dominant side was involved in 15 cases. The mean age of patients at surgery was 61 years (range, 36-79 years). Two patients performed heavy labor, five performed manual labor, eight were sedentary, and thirteen were retired. The initial trauma was a 3-part proximal humeral fracture in 10 and a 4-part fracture in 7. For the 11 other patients, the nature of the fracture was unknown or was classified as a complex fracture. These fractures were managed conservatively in 11 cases and surgically in 17; a closed reduction with intramedullary pinning14 was performed in 9, an open reduction with internal fixation in 6, and the procedure was unknown for 2. Late sequelae of the proximal humeral fractures were incongruence of the glenohumeral joint without any distortion of the proximal humerus in 11, secondary osteonecrosis in 7, osteoarthritis with nonunion in 2, and osteoarthritis with malunion of the proximal humerus in 8. The delay between the initial fracture and shoulder arthroplasty averaged 96 months (range, 12-360 months). The duration of the symptoms before the shoulder arthroplasty procedure averaged 32 months (range, 6-120 months). Patients were evaluated postoperatively by the criteria of Constant and Murley.8 Strength had not been measured before surgery and was measured postoperatively in only 14 patients. The Neer score7,17 was also used for further evaluation of the results at latest follow-up. The criteria for
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considering a result as excellent were as follows: little or no pain, normal use of the arm, anterior elevation greater than 130°, external rotation greater than 90% of that of the contralateral side, and strength within normal range. Satisfactory results included those cases in which moderate pain persisted but the arm could be used almost normally, anterior elevation in the range of 90° to 135°, and external rotation that is 50% of that of the opposite side. Unsatisfactory results comprised those cases not fulfilling the above criteria. Subjective pain evaluation was performed with a visual analog score, in which the patient gives a number from 0 to 15 according to the severity of his or her pain (0 indicates maximum pain and 15 indicates no pain). According to the Constant criteria, the patients’ level of activity and functional range of motion of the affected shoulder were evaluated. Determination of the level of activity was based on such factors as professional handicap, disability in performing daily activities, disturbance of sleep, and the level that could be reached by the hand. Ranges of active anterior elevation and active external rotation were recorded in degrees. Range of internal rotation was measured based on the ability of the thumb to reach vertebral segments. Preoperative, initial postoperative, and most recent radiographs were evaluated for all patients. Four projections were used for analysis: an axillary view, an anterior-posterior view with external rotation of the humerus, an anteriorposterior view with internal rotation of the humerus, and an anterior-posterior view with neutral rotation of the humerus. Of 26 patients, 20 had a computed tomography scan evaluation before surgery to show the incongruence between the humeral head and the glenoid, to identify a possible malunion, and to estimate the bone stock quality and quantity. In 6, a 3-dimensional reconstruction had helped to demonstrate such findings better and also had allowed determination of the anatomic axis of the humerus and the degree of humeral and glenoid version.16 The most recent radiographs were reviewed to determine the presence of periprosthetic lucency, the position of the implants, and the presence of periprosthetic ossification. Glenoid wear was evaluated as concentric or eccentric on the axillary view.13 In 18 cases the glenoid was considered to be concentric (type A according to the classification of Badet et al1), whereas it was eccentric in 10 cases (type B1 according to the classification of Badet et al).
Surgical technique Our technique was similar to that originally described by Neer.18 A total shoulder arthroplasty was performed in 8 cases and a hemiarthroplasty in 20 cases. A Neer II prosthesis (3M, St Paul, MN) was used for 15 patients (7 total shoulder arthroplasties and 8 hemiarthroplasties), and a modular shoulder arthroplasty (3M) was used in the other 13 patients (1 total shoulder arthroplasty and 12 hemiarthroplasties). The humeral component was always cemented. The glenoid component was an all-polyethylene keel-type implant and was also cemented in all cases. A deltopectoral approach was used in all cases except one, in which the existing superior incision scar was used. The deltoid muscle was found to be normal in 26 cases and atrophic in 2. The subscapularis tendon was normal in 17
J Shoulder Elbow Surg May/June 2004
patients and fibrotic in 11. To restore a functional range of external rotation, we had to release the joint capsule from around the glenoid rim and the subscapularis from the scapular neck in 17 patients. In 3 cases a Z-lengthening of the subscapularis tendon was done for the same purpose. The other rotator cuff tendons were normal in 20 patients and torn in 8 (5 isolated supraspinatus ruptures and 3 supraspinatus and infraspinatus lesions). The rotator cuff tear was repaired in 3 cases with isolated supraspinatus lesions, whereas it was not possible to repair it in 1 case with an isolated supraspinatus lesion with malunion of the greater tuberosity and in the 3 cases with combined posterosuperior rotator cuff tears. In another patient, a local flap of the subscapularis muscle was used to replace the defect of the supraspinatus.6 The joint capsule was always incised together with the subscapularis. The biceps tendon was normal in 18 cases, showed pathologic changes in 9 (frayed or inflamed), and was ruptured in 1. A tenodesis was performed for 6 frayed biceps tendons. An osteotomy of the tuberosities was done in 3 cases with malunion to better reattach the tuberosities around the prosthesis, with care taken to leave enough bone attached to the rotator cuff to allow solid fixation. Fixation of the tuberosities was performed with two different types of No. 5 nonabsorbable sutures: horizontal transverse intertuberosity sutures and vertical diaphyseal tuberosity (tension-band system) sutures. Before tuberosity reposition, cancellous autografts were put into the proximal humeral space, filling the spaces between the implant and the tuberosities. The tuberosities were tightened to the lateral fins of the prosthesis, and the tuberosities were then fixed together and to the humeral diaphysis. The rotator cuff interval was then closed with separate sutures. The long head of the biceps was systematically fixed at the intertuberosity interval. The arm was immobilized by means of a sling in internal rotation with the elbow at the side for 6 weeks. In the 3 cases with osteotomy of the greater tuberosity, an abduction splint was used for 6 weeks. On the third postoperative day, a rehabilitation program was started. This program followed the principles described by Neer.18 The time to begin active exercises depended on such factors as the initial etiology, whether an osteotomy of the tuberosity had been performed, and the quality of the rotator cuff. After a mean of 8 days of hospitalization, rehabilitation was continued in a specialized center in 25 cases and 3 patients followed their program with the help of a physiotherapist. The mean stay in the specialized center was 45 days. The mean time of rehabilitation was 6.7 months. Analysis of the data was done with statistical software (StatisticS, Toulouse, France), which allowed analysis of each variable separately and their interrelationship to be studied. A simple regression test was used to define the differences between the preoperative and postoperative values of the same variable. The correlation of each variable with all of the other variables was defined by the simple regression test or Student test.
RESULTS The final results were evaluated after a mean follow-up of 47 months (range, 24-158 months). According to the Neer rating system,17 an excellent
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Figure 1 Radiographic outcome of a 4-part humeral fracture impacted in valgus treated surgically in a 71-year-old patient. A, Anterior-posterior view of the initial fracture. B, Anterior-posterior view of the same shoulder after surgical treatment. C, Two years later, the shoulder developed a malunion of the proximal humerus with humeral head necrosis. D, A humeral head replacement was performed, and at 5 years’ follow-up, the patient had an excellent result according to the Neer rating system, with an adjusted Constant score of 99%.
result was obtained in 7 cases, a satisfactory result in 11, and an unsatisfactory result in 10. Nine patients were very satisfied with their surgery, twelve were
satisfied, and five found very little or no improvement. Two patients considered their symptoms to be worse than before surgery (Figure 1).
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Table I Postoperative assessment of humeral component positioning Radiographic measurement
Results (n ⴝ 28)
Distance Acromiohumeral distance Lateral humeral offset Greater tuberosity lever arm % of diaphyseal filling* Stem positioning†
6.7 mm 7 mm 24.3 mm 8.5 mm 49% –0.85°
*Calculated by dividing the stem width by the inner diaphysis width. If less than 0; the stem is in varus; 0° indicates the stem is normally positioned; if greater than 0°, the stem is in valgus. †
Clinical results
Clinical results were evaluated by the Constant criteria. Postoperatively, 24 patients (85%) had no or very slight pain. The pain score increased from a mean of 1.8 points (range, 0-10 points) to 11 points (range, 5-15 points) (P ⬍ .001). With regard to the activity level, the postoperative mean score increased significantly from 6.2 points (range, 4-10 points) to 14 points (range, 4-20 points) (P ⬍ .001). Fourteen patients were able to use their arms at shoulder level, and seven could use them above this level. Nine patients did not have any sleep disturbance related to the operated shoulder, and this discomfort was minimum for eight. Postoperatively, the mean score for mobility increased from 11 points (range, 4-16 points) to 23 points (range, 2-40 points) (P ⬍ .001). Active anterior elevation improved from a mean of 71° (range, 30°90°) to 107° (range, 40°-180°) (P ⬍ .01). External rotation measured in the standing position increased from a mean of ⫺8° (range, ⫺60° to 20°) to 20° (range, ⫺15° to 70°) (P ⬍ .01). Finally, range of active internal rotation increased from the ability of the thumb to reach the sacrum (range, greater trochanter to the first lumbar vertebral body) to the third lumbar vertebral body (range, trochanter to T7). Strength measured by a dynamometer for 14 patients was estimated at a mean value of 5.2 kg (range, 0-14.6 kg). Finally, the postoperative Constant score, calculated for only 14 patients who had measurement of the muscular force, was equal to 54 points (range, 17-83.6 points). With adjustment by age and sex, it was equal to a mean of 72% (range, 24%-117%). Radiographic analysis
Postoperative radiographs were available for all patients at the most recent follow-up. Periprosthetic ossification was present in 11 cases. It was minimal in 6 cases, predominant at the humeral side in 3, and near the glenoid in 2. No correlation was found
Figure 2 Illustration of humeral component positioning. GTLA, Greater tuberosity lever arm; D, distance; LHO, lateral humeral offset.
between the presence of ossifications and the final results. Correct positioning of the implants was assessed by studying various parameters on the anterior-posterior view with the humerus in neutral rotation (Table I and Figure 2). Nineteen humeral implants were normally positioned, four were found in valgus, and five were in varus. The mean vertical distance between the superior pole of the humeral implant and the superolateral corner of the greater tuberosity was 6.7 mm. In 3 cases the greater tuberosity was above the line drawn at the superior pole of the implant head perpendicular to the humeral axis. These 3 patients had excellent, satisfactory, and unsatisfactory results, respectively. In our series the position of the greater tuberosity was not found to affect the final results (P ⬎ .05). The acromiohumeral distance (AHD) was 7 mm on average (range, 0-13 mm). Fifteen patients had an AHD less than 8 mm. This distance measurement was correlated with postoperative activity (P ⬍ .01), postoperative mobility (P ⬍ .05), and postoperative anterior elevation (P ⬍ .01). The lateral humeral offset was 24.3 mm on average (range, 21-28 mm). This parameter had no influence on the final results. The lever arm of the greater tuberosity had a mean value of 8.5 mm (range, 4-24 mm). Again, we could find no correlation between this factor and the final results. Periprosthetic lucent lines around the humeral component were found in 8 cases. They were incomplete and were seated essentially under the head. In 3 cases, lucent lines were also found around the glenoid implant. These were complete in 1 case surrounding all of the implants and were incomplete in 2 other cases. All of these lucent lines had a width less than or equal to 1 mm, without any progression. In our study we found no case of superior displacement of the glenoid component or loose implants.
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Table II Clinical result at follow-up according to etiology
Cases Pain (out of 15 points) Activity (out of 20 points) Mobility (out of 40 points) Active anterior elevation (°) External rotation (°) Internal rotation (vertebral level) Neer score (excellent and satisfactory) Adjusted Constant score*
Posttraumatic arthritis without distortion
Avascular necrosis
Posttraumatic arthritis and malunion
Posttraumatic arthritis and nonunion
11 12 15 27.5 120 25 6.5 9/11 (82%) 88% (n ⫽ 5)
7 11 14 22.5 108 29 5 4/7 (57%) 69% (n ⫽ 5)
8 9 12 18 91 8 5 4/8 (50%) 69% (n ⫽ 2)
2 7.5 11 16 95 15 3 1/2 (50%) 45% (n ⫽ 2)
Clinical results are expressed according to the Constant criteria.16 *Only 14 patients had a complete Constant score with strength measurement.
We had one complication in this study. One revision surgery was necessary because of a deep infection developing 2 years after the operation. No site of entry could be found, and revision consisted of removal of the implant and joint resection. The patients’ age did not affect the final results, but sex had a significant correlation with measured strength (P ⬍ .001) for the 14 patients tested. Neither the time interval from the initial trauma to surgery nor the duration of symptoms influenced the final results. The type of glenoid noted on preoperative radiographic evaluation (type A or type B11) had no influence on the final outcome. The most important factor for the final results was the integrity of the rotator cuff muscles at surgery. This correlation was significant for postoperative pain score (P ⬍ .01), postoperative activity level (P ⬍ .01), and postoperative mobility (anterior elevation and external rotation). A torn rotator cuff at surgery was correlated with the diminution of the AHD in the postoperative period (P ⬍ .05). An excellent or satisfactory result was obtained in 77% of the patients who had an intact rotator cuff at surgery compared with only 14% for patients with a rotator cuff tear. Subjectively, the patients without a cuff tear were more satisfied with the operation than those with cuff lesions (P ⬍ .01). Postoperatively, the value of the AHD was also correlated with the final results. An excellent or satisfactory result was obtained in 77% of the 13 patients with an AHD of at least 8 mm and in 53% of the 15 patients with an AHD of less than 8 mm. The etiology influenced the final results; better results were obtained in cases with posttraumatic arthritis without any distortion of the tuberosity position, as compared with the cases with osteoarthritis superimposed on the nonunion or malunion. Shoulder arthroplasty for osteoarthritis with malunion or nonunion of the proximal humerus had the least favorable results in our series (Table II). The type of prosthesis (monobloc or modular), as
well as hemiarthroplasty versus total shoulder arthroplasty, had no influence on the outcome (Figure 3). The type of treatment for the initial trauma (conservative versus surgical) also had no influence on the outcome. In this series, osteotomy of the greater tuberosity was performed in only 3 patients, whose final Constant score averaged 36%, and all had unsatisfactory results according to Neer’s criteria. DISCUSSION The management of late sequelae after fracture of the proximal humerus is one of the most challenging problems encountered in shoulder surgery. All bony and soft-tissue pathology must be addressed at the time of arthroplasty to ensure the best result possible. The surgeon has to deal with malunion or nonunion of the proximal humerus, displacement of the tuberosities, bone loss, rotator cuff tears, scarred deltoids, and associated soft-tissue contractures. In addition, many of these shoulders have already undergone surgery. The results of shoulder arthroplasties for old trauma are much less favorable than those of primary osteoarthritis or hemiarthroplasties performed for acute fractures.7,15,17 Few articles in the literature specifically address the results of arthroplasties for posttraumatic sequelae, and only short series of patients have been published (Table III). On the basis of a literature review, a satisfactory result may be expected in 15% to 72% of the cases, with pain relief in more than 85%. However, Frich et al10 found that pain relief was unpredictable. Motion was usually limited, with an active anterior elevation around 110° and an active external rotation around 20°. The results of our study reflected those in the literature, with 85% of the patients having no or slight pain, active anterior elevation improving from a mean of 71° to 107°, and external rotation increasing from a mean of ⫺8° to 20°. The complication rate is usually higher than that
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Figure 3 Radiographic outcome of a 3-part humeral fracture treated conservatively in a 57-year-old patient. A, Anterior-posterior view of the initial fracture. B, One year later, the shoulder developed an avascular necrosis of the proximal humerus. C, Postoperative radiograph at 13 years’ follow-up (158 months) of the shoulder treated by total shoulder arthroplasty. The patient had a satisfactory result according to the Neer rating system, with an adjusted Constant score of 70.5%.
for other etiologies.5,21 The percentage of complications varies from 20% to 48% depending on the series (Table III). The revision rate varies from 3.5% to 35% (Table III). Several factors seem to influence the final results.
Norris et al,19 reviewing the results of 23 cases treated with shoulder arthroplasty for late complications of 3- and 4-part humeral head fractures, emphasized the crucial role of the initial fracture treatment for the final results of arthroplasty; the patients who
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Table III Review of literature reporting results of posttraumatic arthritis treated by shoulder arthroplasty
Author Neer et al17 (1982) Tanner and Cofield21 (1983) Huten and Duparc12 (1986) Frich et al10 (1991) Habermeyer and Schweiberer11 (1992) Dines et al9 (1993) Norris et al19 (1995) Postel et al20 (1995) Bosch et al4 (1998) Beredjiklian et al2 (1998) Boileau et al3 (2001) Current series
Cases
35
28
HHR vs TSA
0/35
28/0
Postoperative GT Satisfactory No or slight motion (AE/ ER) (°) osteotomy results (%) pain (%)
Activity at or above shoulder Complications Revision level (%) (%) (%)
NA
56
NA
NA
NA
NA
NA
NA
NA
89
112/42
NA
43
7
22
5/17
5
22
80
NA
27
NA
NA
27
4/23
NA
15
Unpredictable
NA
NA
26
NA
18
7/11
NA
32
NA
NA
NA
NA
NA
12
70
70
110/31
75
20
10
12
NA
95
92/27
53
48
21
9
19
61
92/22
55
12.5
12.5
20
14/6
23
6/17
48
19/39
14
14/0
NA
NA
NA
60/18
14
NA
NA
24
11/13
13
72
80
107/NA
83
36
34
71 28
46/25 20/8
20 3
42 64
NA 85
102/34 107/20
NA 75
27 3.5
5.6 3.5
HHR, Humeral head replacement; TSA, total shoulder arthroplasty; GT, greater tuberosity; AE, active anterior elevation; ER, active external rotation; NA, not applicable.
had been managed conservatively had a better result than those with initial surgical treatment. We could not show any statistical difference in our study regarding the initial treatment. Dines et al,9 in a more recent study of 20 cases of modular prosthesis, showed a better result for hemiarthroplasty, with a final score of 79.7 out of 100 with the Hospital for Special Surgery scoring system, in contrast to total shoulder replacement, which had a final score of 72 out of 100. In our series we have not found any statistical difference either between the results of hemiarthroplasty and total shoulder arthroplasty or between the results obtained with the monobloc implant (Neer II) versus the modular implant. More than the initial treatment of the fracture or the type of shoulder arthroplasty used, the type of sequelae seems to be one of the most important factors influencing the final results. In the study by Dines et al,9 for posttraumatic arthritis with avascular necrosis, a final score of 87.3 was achieved, whereas a score of 84.1 was obtained for posttraumatic arthritis with nonunion, 72 for humeral head defect, and 69.8 for malunion. For Neer et al,17 the outcome was better for post-dislocation arthropathy, with excellent results
in 76%, whereas 45% of those with post-fracture arthritis achieved excellent results. Recently, Boileau et al3 analyzed the results of shoulder arthroplasties for the treatment of the sequelae of proximal humeral fractures. Sequelae were divided into two categories; category 1 included intracapsular/impacted fracture sequelae (associated with both cephalic collapse or necrosis and chronic dislocation or fracture-dislocation), and category 2 included extracapsular/disimpacted fracture sequelae (associated with both surgical neck nonunions and severe tuberosity malunions). In category 1, the joint could be reconstructed without a greater tuberosity osteotomy, whereas in category 2, a greater tuberosity osteotomy was often needed (17/22 cases) to perform shoulder arthroplasty. The adjusted Constant score was better for sequelae of proximal humeral fractures of category 1 (73%) than for sequelae of category 2 (58.5%). The authors concluded that a greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty in this context and that it must be avoided when possible, with the surgeon accepting the distorted proximal anatomy. In our series better results also were obtained for post-
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traumatic arthritis without any distortion of the tuberosities, with a satisfactory result obtained in 82% of the cases, compared with avascular necrosis, with a satisfactory result obtained in 57%; posttraumatic arthritis with nonunion, with a satisfactory result obtained in 50%; and posttraumatic arthritis with malunion, with a satisfactory result obtained in 50%. The adjusted Constant score was better for posttraumatic arthritis without any distortion of the tuberosities (88%) than for malunion and nonunion (69% and 45%, respectively). Osteotomy of the greater tuberosity was performed in only 3 patients, whose final Constant score averaged 36%, and all had unsatisfactory results according to Neer’s criteria. These results seemed to confirm the general feeling concerning the poor results obtained after greater tuberosity osteotomy. According to our study and to the literature, prognostic factors that seem to influence the final results negatively are as follows: advanced age,9 duration of symptoms,4,20 etiology,3,9,17 rotator cuff tear,21 osteotomy of the tuberosity,3,9,21 and use of hemiarthroplasty versus total shoulder arthroplasty.9 The length of the rehabilitation time seems to be a very important factor for the final result.4,21 Bosch et al4 stated that what seems to be more important for rehabilitation, however, is the cooperation and mental state of patients, rather than their age. Conclusions
Shoulder arthroplasty for management of posttraumatic complications of fracture of the proximal humerus is a technically demanding procedure with unpredictable results. The high rate of complications is often related to technical difficulties, a scarred deltoid, adhesions of rotator cuff tendons, and malunion of the tuberosities. Careful selection of patients and preoperative planning are essential elements that guarantee achievement of good results. Greater tuberosity osteotomy must be avoided when possible, even if there is a distorted proximal humerus. If there is no impingement because of the tuberosity malunion, the shoulder arthroplasty must be adapted to the proximal humerus. The postoperative rehabilitation program should be modified based on the surgical findings and the technique used. In this manner, certain possible secondary complications could be avoided, and the long-term results will be more favorable.
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REFERENCES
1. Badet R, Walch G, Boulahia A. L’examen tomodensitome´trique dans l’omarthrose centre´e primitive. Rev Rhum Ed Fr 1998;65: 203-10. 2. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am 1998;80:1484-97. 3. Boileau P, Trojani C, Walch G, et al. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 2001;10:299-308. 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; 7:479-84. 5. Cofield RH, Edgerton B. Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect 1990;39:449-62. 6. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet 1982;154:66772. 7. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am 1984;66:899-906. 8. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop 1987;214:160-4. 9. Dines DM, Warren RF, Altchek DW, Moeckel B. Posttraumatic changes of the proximal humerus: malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty. J Shoulder Elbow Surg 1993;2:11-21. 10. Frich LH, Sojbjerg JO, Sneppen O. Shoulder arthroplasty in complex acute and chronic proximal humeral fractures. Orthopedics 1991;9:949-54. 11. Habermeyer P, Schweiberer L. Corrective interventions subsequent to humeral head fractures. Orthopade 1992;21:148-57. 12. Huten D, Duparc J. Prosthetic arthroplasty in recent and old complex injuries of the shoulder [in French]. Rev Chir Orthop Reparatrice Appar Mot 1986;72:517-29. 13. Levine WN, Djurasovic M, Glasson JM, et al. Hemiarthroplasty for glenohumeral osteoarthritis: results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-54. 14. Mansat M, Bellumore Y, Mansat P. Four-part proximal humerus fractures. In: Fu FH, Ticker JB, Imhoff AB, editors. An atlas of shoulder surgery. London: Martin Dunitz Ltd; 1998. p. 251-8. 15. Mansat M, Blazy O, Mansat P. Omarthroses centre´es. Rev Chir Orthop Reparatrice Appar Mot 1995;81(Suppl II):106-8. 16. Mansat M, Fourcade D. Preoperative planning in shoulder prosthesis [in French]. Acta Orthop Belg 1995;61(Suppl I):73-8. 17. Neer CS II, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-37. 18. Neer CS II. Glenohumeral arthroplasty. In: Neer CS II, editor. Shoulder reconstruction. Philadelphia: Saunders; 1990. p. 143269. 19. Norris TR, Green A, McGuigan FX. Late prosthetic shoulder arthroplasty for displaced proximal humerus fractures. J Shoulder Elbow Surg 1995;4:271-80. 20. Postel JM, Tamames M, Lenoble E, Goutallier D. Les arthroses post-traumatiques. Rev Chir Orthop Reparatrice Appar Mot 1995;81(Suppl II):111-5. 21. Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop 1983; 179:116-28. 22. Wirth M, Rockwood C. Current concepts review: complications of total shoulder replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-16.