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.


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Figure Legends

mccormack fig1

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

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

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Figure 3: Modular, cemented, hemi arthroplasty.