Role of Prosthetic Replacement for Proximal Humerus Fractures

Robert G. McCormack M.D. FRCSC
Assistant Professor
University of British Columbia
New Westminster, BC

Damian Musso M.D.
Orthopaedic Fellow
University of British Columbia

Complex fractures of the proximal humerus remain one of the most challenging problems in orthopaedic surgery. There is a significant complication rate, irrespective of how they are managed, and a paucity of data to support one treatment modality over another. Perhaps more than any other injury, the fracture personality is the key to determining treatment. Several factors need to be considered, including patient demands and co-morbidities, the fracture pattern, bone quality, soft tissue status and surgeon experience. The average age for proximal humerus fracture is 66 years old and there is a trend for fracture complexity to increase with age. Superimposed on this, almost all patients that fracture the proximal humerus over age 40 have osteopenia, which makes standard ORIF more challenging.

The most common fracture indications for humeral head replacement are four part, and selected three part fractures in this older age group (see Figure 1). This is because of the high incidence of osteonecrosis (10% in three part fractures)1 and the challenges of internal fixation of comminuted fractures in osteopenic bone.

In a classic paper in 19701, Neer compared the results of nonoperative treatment with hemi-arthroplasty for these injuries. There were no satisfactory results in the nonoperative group due to inadequate reduction, non-union, mal union and humeral head osteonecrosis with collapse. Stableforth2 confirmed this in a study where patients were randomized to nonoperative management or prosthetic replacement. The patients with displaced fractures treated nonoperatively, had worse overall results (for pain, range of motion and ADLs).

Multiple studies have shown satisfactory results with open reduction internal fixation in young patients with good bone quality as long as secure fixation of the fragments can be achieved and maintained3-7. Unfortunately, the majority of complex proximal humerus fractures occur in elderly patients with poor bone quality and fixation of fracture fragments can often be tenuous (see Figure 2). This is one of the main reasons to consider hemiarthroplasty as a treatment.

Multiple studies8-15 have reported good pain relief following a hemi-arthroplasty for three and four part fractures. Return of good function is much less predictable but, fortunately, the functional demands of an individual in his or her 80s are 65-80% of a 30 year olds. Ideally, the decision regarding definitive treatment is made in the early post injury period, as the results of humeral head replacement are better if the surgery is performed acutely (within four weeks) rather than in the sub-acute or chronic phase16. The results are also compromised when an arthroplasty is performed after failed internal fixation12, 17-19. Mal union or non-union of the tuberosities and capsular scarring contribute to the poor results in this group of patients.

As in most areas of orthopaedics, the first shot is the best one. Once the decision is made to perform a humeral head replacement, it is very important to pay attention to the technical details of the procedure. This includes the correct version and size of the humeral head (do not overstuff) and the height of the component (correct tissue tension). Given the associated fractures of the tuberosities, this necessitates the use of a cemented humeral stem in almost all cases (see Figure 3). It is critical to obtain a solid repair of the cuff and fixation of the tuberosities to the shaft, to the prosthesis and to each other. I recommend use of a modular head in all but the lowest demand individuals, to facilitate any future revision surgery.

Misra20 and Bhandari21 attempted to perform systemic reviews of the literature, but found only a small number of trials that were eligible over the last 30 years. Their conclusions were that the literature was inadequate for a true evidence based decision on what is the best form of treatment for this injury. There was, however, a trend for the arthroplasty patients to have better range of motion, and less pain than those treated nonoperatively or with open reduction internal fixation. While four part and selected three part fractures are the most common indication for a humeral hemi arthroplasty, the same principles apply to displaced two part fractures of the anatomic neck where avascular necrosis is a significant risk. Another indication for performing an arthroplasty would be the older patient with incongruity of the articular surface. This can occur because of a head splitting fracture or because of a fracture dislocation with a large Hills Sachs, or reversee Hill Sachs, lesion (typically involving more than 40% of the articular surface). The last group of proximal humerus fractures, where an arthroplasty is usually considered the treatment of choice, are pathologic fractures. As noted above, significant osteopenia is probably the most common cause of pathologic fracture, but both benign and malignant lesions of bone can compromise standard internal fixation techniques to make arthroplasty a preferable option.

In summary, complex fractures of the proximal humerus remain an unsolved problem. Hemi arthroplasty offers reasonably predictable pain relief and, with attention to appropriate technique, acceptable function. The results are not perfect, but in osteopenic bone, current techniques of internal fixation are even more problematic.

References

1. Neer C.S. Displaced Proximal Humeral Fractures. Part II: Treatment of 3-Part and 4-Part Displacement. J.Bone Joint Surg. 1970;52:1090-1103

2. Stableforth P.G: Four-part Fractures of the Neck of the Humerus. J Bone Joint Surg Br 1984;66:104-108

3. Resch H., Beck E., Bayley I. Reconstruction of the Valgus-Impacted Humeral Head Fracture. J Shoulder Elbow Surg. 1995;4:73-80

4. Gerber C., Hersche O., Berberat C. The Clinical Relevance of Post Traumatic Avascular Necrosis of the Humeral Head. J Shoulder Elbow Surg. 1998;7:586-590

5. Cuomo F., Flatow E.L., Maday M.G., Miller S.R., McIlveen S.J., Bigliani L.U. Open Reduction and Internal Fixation of Two and Three-Part Displaced Surgical Neck Fractures of the Proximal Humerus. J Shoulder Elbow Surg. 1992;1:287-295

6. Esser R.D.. Treatment of 3 and 4 Part Fractures of the Proximal Humerus with a Modified Cloverleaf Plate. J Orthop Trauma. 1994;8:15-22

7. Savoie F.H., Gissler W.B., Vander Griend R.A. Open Reduction and Internal Fixation of 3-Part Fractures of the Proximal Humerus. Orthopaedics 1989;12:65-70

8. Goldman R.T., Koval K.J., Cuomo F., Gallagher M.A., Zuckerman J.D. Functional Outcome after Humeral Head Replacement for Acute Three and Four-Part Proximal Humeral Fractures. J Shoulder Elbow Surg 1995;4:81-86

9. Hawkins R.J., Switlyk P. Acute Prosthetic Replacement for Severe Fractures of the Proximal Humerus. Clin Orthop 1993;289:156-160

10. Neer C.S. II. Articular Replacement for the Humeral Head. J Bone Joint Surg Am 1995;37:215-228

11. Zyto K., Wallace W.A., Frostick S.P., Preston B.J. Outcome After Hemiarthroplasty for Three and Four Part Fractures of the Proximal Humerus. J Shoulder Elbow Surg 1998;7:85-89

12. Tanner M.W., Cofield R.H. Prosthetic Arthroplasty for Fractures and Fracture-Dislocations of the Proximal Humerus. Clin Orthop 1983;179:116-128

13. Dines D.M., Warren R.F., Altchek D.W., Moeckel B. Post Traumatic Changes of the Proximal Humerus: Malunion, and Osteonecrosis Treatment with Modular Hemiarthroplasty or Total Shoulder Arthroplasty. J Shoulder Elbow Surg 1993;2:11-21

14 Wretenberg P., Ekelund A. Acute Hemiarthroplasty after Proximal Humerus Fracture in Old Patients: A Retrospective Evaluation of 18 Patients Followed for 2-7 Years. Acta Orthop Scand 1997;68:121-123

15. Mighell M.A., Kolm G.P., Gollinge C.A., Frankle M.A. Outcomes of Hemiarthroplasty for Fractures of the Proximal Humerus. J Shoulder Elbow Surg 2003;12(6):569-577

16. Bosch U., Skutek M., Fremerey R.W., Tscherne H. Outcome After Primary and Secondary Hemiarthroplasty in Elderly Patients with Fractures of the Proximal Humerus. J Shoulder Elbow Surg 1998;7:479-484

17. Boileau P., Krishnan S.G., Tinsi L., Walch G., Coste J.S., Mole D. Tuberosity Malposition and Migration: Reasons for Poor Outcomes after Hemiarthroplasty for Displaced Fractures of the Proximal Humerus. J Shoulder Elbow Surg 2002, Sept-Oct;11(5):401-12

18. Frich L.H., Sojbjerg J.O., Sneppen O. Shoulder Arthroplasty in Complex Acute and Chronic Proximal Humeral Fractures. Orthopaedics 1991;14:949-954

19. Norris T.R., Green A., McGuigan F.X. Late Prosthetic Shoulder Arthroplasty for Displaced Proximal Humerus Fractures. J Shoulder Elbow Surg 1995;4:271-280

20. Misra A., Kapur R., Maffulli N. Complex Proximal Humeral Fractures in Adults: A Systematic Review of Management. Injury 2001 Jun;32(5):363-72

21. Bhandari M., Matthys G., McKee M.D. Four Part Fractures of the Proximal Humerus. J Orthop Trauma 2004 Feb;18(2):126-7.

Figure Legends

mccormack fig1

Figure 1: Comminuted four part proximal humerus fracture in 74-year-old female.

mccormack fig2

Figure 2: Failed ORIF with pain and limited range of motion.

mccormack fig3

Figure 3: Modular, cemented, hemi arthroplasty.

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