**1. Introduction**

532 Recent Advances in Arthroplasty

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Experience with Lumbar Total Disc Replacement as Part of the IDE Study of the

Drug Administration investigational device exemption study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: five-year

disc replacement surgery for symptomatic degenerative lumbar disc disease: a

We present a review of the most recent published articles related to shoulder hemiarthroplasty in proximal humerus fractures. Four-part proximal humerus fractures represent between 2% and 10% of all proximal fractures where displacement occurs as a result of the muscular deforming force.

Hemiarthroplasty is indicated in patients with four-part fractures and in elderly patients with osteoporotic bone who have fracture-dislocations. In both groups of patients, obtaining a secure stable reduction using internal fixation techniques is difficult, and the rate of osteonecrosis can range from 13% to 35% in four-part fractures. Hemiarthroplasty can also be considered in patients with three-part fractures and fracture-dislocations when bone quality is poor and the degree of conminution precludes satisfactory reduction and internal fixation. Headsplitting proximal humerus fractures in elderly patients also should be treated with hemiarhroplasty. Primary replacement can be considered in younger patients with four-part proximal fractures if acceptable redution cannot be obtained.

The important surgical principles when performing a hemiartroplasty for four-part proximal humeral fractures include the following: the use of a deltopectoral approach, allowing preservation of the deltoid origin and insertion; restoration of humeral length and retroversion; and secure fixation of the tuberosities to the prosthesis, to the shaft and to one another.

Results of hemiarthroplasty for four-part proximal humerus fractures are somewhat difficult to interpret, specifically because other proximal humerus fracture patterns often are included in published series. Wide variation in outcomes measurements also makes comparisons between studies difficult. Despite these limitations, hemiarthroplasty offers reliable pain relief and reasonable levels of patient satisfaction, but only modest functional results. Limited use with activities of daily living below shoulder level may be reliably obtained but overhead use is not typical following this surgery.

Significant residual pain generally tends to be associated with moderate activity: minimal pain occurs at rest. Even when motion and functional results are limited, pain relief is reported to be consistent.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 535

program. In patients with known chronic large rotator cuff tears, the results of humeral head replacement for fracture are poor (Compito et al 1994) and this may be an indication for the use of a Reverse Total Shoulder Arthroplasty (RTSA). Indications and technical recommendations for the use of the RTSA in this setting are not clearly defined but this

Prosthetic replacement for proximal humerus fractures is a challenging operation with variable results reported in the orthopaedic literature especially in terms of patient function (Robinson et al 2003). This procedure is performed uncommonly even by shoulder specialists. Anatomic landmarks are lost due to fracture of the tuberosities away from the humeral shaft making proper placement of prosthesis in terms of height and version a challenge. Tuberosities may be comminuted and the deforming pull of the rotator cuff tendons represents a challenge to fracture healing. Excellent results following humeral head replacement for fracture are associated with proper implant selection and insertion, anatomic tuberosity healing, and early rehabilitation to restore motion and strength**3**. Conversely, poor results are most commonly associated with tuberosity malunion or nonunion and improper humeral stem positioning (Bolileau et al 2002, Demirhan et al 2003, Esen et al 2009, Frankle et al 2001, Robinson et al 2003). Other important factors include the timing of surgery, patient age, tobacco and alcohol use, and female sex. Despite intensive study and improvements in patient selection, prosthetic design, and surgical technique, functional results remain variable. Wide variation in outcomes measurements also makes comparisons between studies difficult. Despite these limitations, hemiarthroplasty offers reliable pain relief and reasonable levels of patient satisfaction, but only modest functional results. Limited use with activities of daily living below shoulder level may be reliably obtained but overhead use is not typical following this surgery. Good to excellent results remain between 75-85% despite these challenges (Bigliani 1990, Goldman et al 1995, Green et al 1993, Kontakis et al 2008, Moeckel et al 1992, Robinson et al 2003, Tanner & Cofield 1983). High satisfaction rates seem to correlate more with pain relief than with range of motion or functional outcomes. Even studies with poor functional results report high patient satisfaction if pain relief is acceptable. Certainly, the more prepared the surgeon finds him or herself in the management of the patient with a severely displaced proximal humeral fracture, the better the chance of success. The purpose of this article is to review the preoperative evaluation, describe the surgical technique required for successful placement of the prosthesis and fixation of the tuberosities, and outline a safe postoperative rehabilitation program. We will review current results and complications associated with the technique of humeral head replacement and Reverse total shoulder arthroplasty for

represents an area of exciting new research (Franke et al 2002, Wall & Walch 2007).

proximal humeral fractures.

**2.1 Preoperative evaluation** 

**2. Shoulder arthroplasty for proximal humerus fractures** 

Adequate preoperative evaluation is critical in the management of patients with displaced proximal humerus fractures. The surgeon must have a good working knowledge as to the mechanism of injury and level of energy associated as this will give an indication of possible neurovascular injuries. The surgeon should attempt to determine whether the injury represents a fracture or a fracture/dislocation and evaluation of all available radiographic studies is beneficial. Previous history of osteoporosis will give an indication as to the quality of bone available for fixation. Past history of rotator cuff disease is helpful as a large rotator

Reports of patient satisfaction vary widely, in part because of the numerous scales used to measure outcomes and satisfaction. High satisfaction rates seem to correlate more with pain relief than with range of motion of functional outcomes. Even studies with poor functional results report high patient satisfaction if pain relief is acceptable.

The prognostic factors have been shown to be the age, the delay between injury and surgery, preoperative neurologic deficit, history of cigarette smoking, excessive alcohol consumption and female sex. Tuberosity position and healing may be the most important factors in determining outcome.

Recently the use of the Reverse Total Shoulder Replacement has been recommended in selected cases of proximal humeral fracture. Although the indications and results of this technique are not well known yet, this may offer an advantage in selected cases over traditional Humeral Head Replacement. Any possible advantages of this technique must be weighed against increased risks and the known results of humeral head replacement.

Humeral head replacement is indicated for a select group of proximal humeral fractures depending on the severity and pattern of the fracture as well as bone quality and cuff integrity (Compito et al 1994). The results of this surgery are dependent on patient factors, timing of surgery, and technical factors associated with the performance of the operation. The majority of fractures of the proximal humerus can be treated nonoperatively but a full 15% of cases will require some type of operative interventio (Young et al 1985, Zuckerman et al 2007). Neer's fracture classification has generally served as a reliable guide to fracture managemen (Neer et al 1970, 1970). The more severe the injury, the higher the risk of avascular necrosis of the humeral head, malunion, or nonunion of the fracture. When indicated, early surgical intervention leads to superior results and avoids many complications associated with delayed management (Demirhan et al 2003, Duralde & Leddy 2010).

Operative treatment options for proximal humeral fractures include various forms of open or closed reduction and fixation versus prosthetic replacement. The introduction of the proximal humeral locking plate has expanded the indications for ORIF as patients with osteoporotic bone can now be better managed utilizing this plate for fixation (Duralde & Leedy 2010). Even cases of late avascular necrosis following ORIF can be managed effectively with hardware removal and prosthetic replacement as long as the tuberosities have healed in a relatively anatomic position (Boileau et al 2001). Similarly advances in the technique of closed reduction and percutaneous pinning have increased the indications for this modality (Jaberg et al 1992). ORIF remains a good option for displaced 2-part fractures, 3-part fractures (even in the face of osteoporosis), and impacted valgus 4-part fractures of the proximal humerus (Bastian & Hertel 2009, Duralde & Leedy 2010). Four-part fractures in young patients are preferably treated with a locking plate but if stable fixation cannot be attained, humeral head replacement is indicated. A group of fractures remain, however, that are not amenable to this modality and require prosthetic replacement for adequate management.

Prosthetic replacement for proximal humeral fractures remains the treatment of choice for 4 part fracture dislocations, head-split fractures, and head impaction fractures of ›40%. These fractures represent between 2 and 10% of proximal humeral fractures (Zuckerman & Sajadi 2007). It remains a good option in comminuted 3-part fractures especially in elderly patients with poor bone quality or a high degree of comminution (Bigliani 1990). Humeral head replacement is contraindicated in cases of active infection, severe nerve palsy to the deltoid and rotator cuff, and in patients unable to comply with the postoperative rehabilitation

Reports of patient satisfaction vary widely, in part because of the numerous scales used to measure outcomes and satisfaction. High satisfaction rates seem to correlate more with pain relief than with range of motion of functional outcomes. Even studies with poor functional

The prognostic factors have been shown to be the age, the delay between injury and surgery, preoperative neurologic deficit, history of cigarette smoking, excessive alcohol consumption and female sex. Tuberosity position and healing may be the most important factors in

Recently the use of the Reverse Total Shoulder Replacement has been recommended in selected cases of proximal humeral fracture. Although the indications and results of this technique are not well known yet, this may offer an advantage in selected cases over traditional Humeral Head Replacement. Any possible advantages of this technique must be weighed against increased risks and the known results of humeral head replacement. Humeral head replacement is indicated for a select group of proximal humeral fractures depending on the severity and pattern of the fracture as well as bone quality and cuff integrity (Compito et al 1994). The results of this surgery are dependent on patient factors, timing of surgery, and technical factors associated with the performance of the operation. The majority of fractures of the proximal humerus can be treated nonoperatively but a full 15% of cases will require some type of operative interventio (Young et al 1985, Zuckerman et al 2007). Neer's fracture classification has generally served as a reliable guide to fracture managemen (Neer et al 1970, 1970). The more severe the injury, the higher the risk of avascular necrosis of the humeral head, malunion, or nonunion of the fracture. When indicated, early surgical intervention leads to superior results and avoids many complications associated with delayed management (Demirhan et al 2003, Duralde &

Operative treatment options for proximal humeral fractures include various forms of open or closed reduction and fixation versus prosthetic replacement. The introduction of the proximal humeral locking plate has expanded the indications for ORIF as patients with osteoporotic bone can now be better managed utilizing this plate for fixation (Duralde & Leedy 2010). Even cases of late avascular necrosis following ORIF can be managed effectively with hardware removal and prosthetic replacement as long as the tuberosities have healed in a relatively anatomic position (Boileau et al 2001). Similarly advances in the technique of closed reduction and percutaneous pinning have increased the indications for this modality (Jaberg et al 1992). ORIF remains a good option for displaced 2-part fractures, 3-part fractures (even in the face of osteoporosis), and impacted valgus 4-part fractures of the proximal humerus (Bastian & Hertel 2009, Duralde & Leedy 2010). Four-part fractures in young patients are preferably treated with a locking plate but if stable fixation cannot be attained, humeral head replacement is indicated. A group of fractures remain, however, that are not amenable to this modality and require prosthetic

Prosthetic replacement for proximal humeral fractures remains the treatment of choice for 4 part fracture dislocations, head-split fractures, and head impaction fractures of ›40%. These fractures represent between 2 and 10% of proximal humeral fractures (Zuckerman & Sajadi 2007). It remains a good option in comminuted 3-part fractures especially in elderly patients with poor bone quality or a high degree of comminution (Bigliani 1990). Humeral head replacement is contraindicated in cases of active infection, severe nerve palsy to the deltoid and rotator cuff, and in patients unable to comply with the postoperative rehabilitation

results report high patient satisfaction if pain relief is acceptable.

determining outcome.

Leddy 2010).

replacement for adequate management.

program. In patients with known chronic large rotator cuff tears, the results of humeral head replacement for fracture are poor (Compito et al 1994) and this may be an indication for the use of a Reverse Total Shoulder Arthroplasty (RTSA). Indications and technical recommendations for the use of the RTSA in this setting are not clearly defined but this represents an area of exciting new research (Franke et al 2002, Wall & Walch 2007).

Prosthetic replacement for proximal humerus fractures is a challenging operation with variable results reported in the orthopaedic literature especially in terms of patient function (Robinson et al 2003). This procedure is performed uncommonly even by shoulder specialists. Anatomic landmarks are lost due to fracture of the tuberosities away from the humeral shaft making proper placement of prosthesis in terms of height and version a challenge. Tuberosities may be comminuted and the deforming pull of the rotator cuff tendons represents a challenge to fracture healing. Excellent results following humeral head replacement for fracture are associated with proper implant selection and insertion, anatomic tuberosity healing, and early rehabilitation to restore motion and strength**3**. Conversely, poor results are most commonly associated with tuberosity malunion or nonunion and improper humeral stem positioning (Bolileau et al 2002, Demirhan et al 2003, Esen et al 2009, Frankle et al 2001, Robinson et al 2003). Other important factors include the timing of surgery, patient age, tobacco and alcohol use, and female sex. Despite intensive study and improvements in patient selection, prosthetic design, and surgical technique, functional results remain variable. Wide variation in outcomes measurements also makes comparisons between studies difficult. Despite these limitations, hemiarthroplasty offers reliable pain relief and reasonable levels of patient satisfaction, but only modest functional results. Limited use with activities of daily living below shoulder level may be reliably obtained but overhead use is not typical following this surgery. Good to excellent results remain between 75-85% despite these challenges (Bigliani 1990, Goldman et al 1995, Green et al 1993, Kontakis et al 2008, Moeckel et al 1992, Robinson et al 2003, Tanner & Cofield 1983). High satisfaction rates seem to correlate more with pain relief than with range of motion or functional outcomes. Even studies with poor functional results report high patient satisfaction if pain relief is acceptable. Certainly, the more prepared the surgeon finds him or herself in the management of the patient with a severely displaced proximal humeral fracture, the better the chance of success. The purpose of this article is to review the preoperative evaluation, describe the surgical technique required for successful placement of the prosthesis and fixation of the tuberosities, and outline a safe postoperative rehabilitation program. We will review current results and complications associated with the technique of humeral head replacement and Reverse total shoulder arthroplasty for proximal humeral fractures.
