AAOS Now

Published 5/1/2010
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Maureen Leahy

Reverse vs. hemi for 4-part humeral fractures

Patient selection, technique are key to success

Hemiarthroplasty (HA) has traditionally been the treatment of choice for elderly patients with four-part proximal humeral fractures. In recent years, however, reverse shoulder arthroplasty (RSA) has been explored as an alternative to HA in these instances. The 2010 American Shoulder and Elbow Surgeons (ASES) Specialty Day symposium, “Reverse vs. Hemi for Complex 4-Part Proximal Humeral Fractures,” moderated by Christian Gerber, MD, explored both treatment methods.

Is RSA an effective alternative?
“Hemiarthroplasty for fractures in elderly patients is at risk for failure,” Pascal Boileau, MD, told symposium attendees. This is especially true, he said, in patients older than age 75 who have comorbidities, osteoporosis, or rotator cuff tears.

RSA has been used successfully in treating cuff tear arthropathy. Because it uses a reverse prosthesis designed to enable the artificial joint to function in spite of significant bone loss or rotator cuff deficiency, it may be an alternative to HA for elderly patients. Improvements in the design of the reverse prosthesis as well as in the surgeon’s technique could lead to even better results than HA.

Dr. Boileau cited a prospective, randomized study that compared RSA and HA in acute fracture patients. Each group comprised 28 patients older than age 70; the average age of the RSA group was 79 years, the average age of the HA group was 76 years. Among the 20 patients in the RSA group and 23 patients in the HA group available for follow-up at 33 months, researchers reported the following results:

  • Functional results showed RSA restored anterior active elevation better than HA (122 degrees vs. 109 degrees, p = 0.07).
  • RSA was slightly better than HA in relieving pain.
  • External rotation, however, was better in the HA group.

“The main finding of this study was that RSA results are more predictable than HA results,” Dr. Boileau said. The study also underscored the importance of greater tuberosity healing in restoring external rotation.

Other problems currently associated with treating fractures with RSA, he said, include instability, infection, and implant deterioration/loosening. According to Dr. Boileau, to avoid notching and instability, the surgeon should place the prosthesis as high as possible and the baseplate as low as possible. He personally prefers a prosthetic design that is low profile, bone-preserving, monobloc, and universal.

“The most important recommendation I can give you,” he said, “is to put the prosthesis higher than the greater tuberosity when it is reduced.”

Dr. Boileau believes use of the reverse-shoulder prosthesis can simplify postoperative care and contribute to a more rapid recovery, more predictable results, better fixation of the greater tuberosity, and better healing of acute fractures. This is especially true for patients older than age 75, for women with osteopenia, and for patients with comorbidities, poor blood supply, and poor compliance with rehabilitation. Patients with greater tuberosity comminution, thin cortical bone, combined fractures of the glenoid and humerus, and severe fatty infiltration of the rotator cuff muscles are also good candidates for RSA.

Figure 1: Diagram of suture configuration for reattachment of tuberosities to the prosthesis and to proximal humerus.

Technique matters
Indications for humeral head replacement (HHR) in four-part fractures include medial metaphyseal comminution, lateral head displacement, fracture dislocations, and head splitting fractures, according to Louis U. Bigliani, MD.

Because four-part proximal humeral fractures are very difficult to treat, he stressed the importance of meticulous technique and getting it right the first time.

“No matter what method you choose (percutaneous pin fixation, open reduction/internal fixation, hemiarthroplasty, or reverse prosthesis), your technique must be meticulous,” he said. “You want a successful result the first time because a malunion or a failed prosthesis is extremely difficult to treat. It is best not to have a situation where you have to revise what you’ve done.”

A successful procedure depends on proper prosthesis positioning and secure tuberosity reconstruction that will allow early passive assistive rehabilitation. Active rehabilitation is only done after the tuberosities are healed.

“At the end of the reconstruction, the surgeon should move the arm in different positions to test the fixation. This will ensure that the patient will be able to do early rehabilitation,” Dr. Bigliani said.

He reminded the audience that 20 years ago, patients stayed in the hospital for 10 to 12 days and their rehabilitation was closely supervised. “Patients couldn’t go home until they broke the horizontal plane,” he said. “Today, I think we’ve lost that supervision of patients. What may happen is that patients are advanced too quickly or do active exercises and the tuberosities displace, which is the leading complication.”

Dr. Bigliani cited published studies that illustrate tuberosity issues in both RSA and HA. In a study involving 43 RSA patients (average age 78 years), tuberosity displacement was present in 53 percent of patients at 22 months mean follow-up. Similarly, a comprehensive literature review of 16 studies that included a total of 808 HA patients (average age 67.7 years) found that at 6 weeks postop, 11.5 percent of complications were related to fixation and healing of the greater tuberosity. At final follow-up, most patients reported mild or no pain but functional limitations still persisted.

Dr. Bigliani said he and his team have had good results in recent years in performing HHR on patients with four-part and head-split fractures. “We really concentrated on tuberosity fixation and rehabilitation,” he reported. When they performed an RSA on an 84-year-old woman with severe osteoporosis, “the important thing was to get the tuberosities attached to the prosthesis and the bone.

“Numerous studies have demonstrated that HHR for fracture provides reliable pain relief and improved function; however, function is really dependent on tuberosity repair,” he said. “The message is that you have to fix the tuberosities.”

When selecting a treatment method, Dr. Bigliani concluded, surgeons should opt for “the treatment that provides the most predictable long-term outcome in your hands. It’s a choice thing —you shouldn’t be forced to do something you are uncomfortable doing.”

Disclosure information: Dr. Boileau—Tornier, DePuy, and Smith & Nephew; Dr. Bigliani— Zimmer, Arthrex, Inc., EBI, Medtronic, Stryker. Links to the studies cited in this article can be found in the online version, available at www.aaosnow.org

Maureen Leahy is assistant managing editor for AAOS Now. She can be reached at leahy@aaos.org

Bottom line

  • Reverse shoulder arthroplasty (RSA) should be considered for patients older than age 75, for women with osteopenia, and for patients with comorbidities, poor blood supply, and poor observance of rehabilitation.
  • Problems associated with RSA include loss of external rotation, instability, infection, and implant deterioration/loosening.
  • Indications for hemiarthroplasty in four-part fractures include dislocation, medial metaphyseal comminution, and lateral head displacement.
  • Problems associated with hemiarthroplasty include tuberosity displacement, prosthesis malpositioning, functional limitations, and poor rehabilitation.

Online references:

  1. Bufquin T, Hersan A, Hubert L, Massin P: Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: A prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br 2007;89(4):516-520.
  2. Kontakis G, Koutras C, Tosounidis T, Giannoudis P: Early management of proximal humeral fractures with hemiarthroplasty: A systematic review. J Bone Joint Surg Br 2008;90(11):1407-1413.