Saturday, October 8, 2016

Hemiarthroplasty for proximal humerus fractures

There is currently discussion about whether a hemiarthroplasty or a reverse shoulder arthroplasty should be offered to elderly patients with osteopenia or 4 part proximal humerus fractures. The supporters of the reverse shoulder arthroplasty state that there is better pain relief after the surgery and if the tuberosities heal then the ROM will be satisfactory. The supporters of the hemiarthroplasty state that the procedure is revisable, if the tuberosities heal then the ROM is satisfactory most of the time, but if they do not then the patient will have poor ROM.

One of the main concerns of the reverse shoulder arthroplasty is still tuberosity healing.

1. Studies show that tuberosity healing is still of importance to avoid loss of motion after surgery
2. The tensioning of the soft tissues after reverse shoulder arthroplasty for fracture is not easy to be achieved as in primary surgery for arthritis. If the tuberosity healing fails then the construct can loose tension and dislocation may occur.
3. If the reverse arthroplasty fails,  then there is no easy solution other than conversion to (a) a hemiarthroplasty or (b) resection arthroplasty. Both of these procedures have poor outcomes

Below we demonstrate a patient who was treated with a hemiarthroplasty for a 4 part proximal humerus fracture. She is her 60s and for that reason we elected to proceed with a hemiarthroplasty. Although anatomic reduction of the tuberosities is important it seems that most important factor is the healing even if they are over-reduced.

The patient was pain free at 3 months postoperatively, her active forward elevation was equal to the opposite site. The final X-rays reveal healed but "over-reduced tuberosities".