**3.3 Prognostic factors**

Patient age has been shown to be predictive of outcome. Younger patients have improved results, gaining more rang of motion and a higher level of functional return. These improved results are attributed, in part, to motivation and compliance with postoperative rehabilitation and a more structurally intact rotator cuff.

Another prognostic factor is the delay between injury and surgery. A long delay between the time of injury and surgery has been shown to result in poorer postoperative range of motion and decreased functional outcomes. Although the time frames vary across studies, surgery within 1 week of injury seems to be associated with improved outcomes.

Other preoperative factors that correlate with a poor result are preoperative neurologic deficit, a history of cigarette smoking, excesve alcohol consumption, and female sex. Poorer results associated with the latter are somewhat controversial because in the studies that identified ths finding, women were significantly older than men, which is a significant confounding variable.

Tuberosity position and healing may be the most important factors in determining outcome. Greater tuberosity malunion is the most common complication associated with hemiarthroplasty for four-part proximal humerus fractures. Final tuberosity position of more than 5 mm above or more than 10 mm below the prosthetic head is associated with poor results. A final position of more than 2 cm below the prosthetic humeral head also

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 559

If the component is placed in an incorrect amount of version or if humeral length is not properly restored, the risk of instability is greater. Careful attention to positioning the component intraoperatively and managining that position during cementing is essential. Inserting the component in proper version requires the use of consistent landmarks. Obtaining proper version and length during cementing can be difficult; therefore, we find the use of intraoperative fracture jigs to be beneficial. Component malposition can be prevented if a reliable method to obtain and mantain malposition during insertion is used. We believe that cemented fixation of these components is mandatory to mantain position,

The so-called ''unhappy triad,'' involves prosthesis with excessive height and retroversion and the greater tuberosity is positioned too low. This combination was frequently associated with poor functional results and persistent pain and stiffness. Studies have also demonstrated that acute reconstruction (less than four weeks after the injury) results in better functional outcomes because of the ease of tuberosity reconstruction (Boileau et al

Rotator cuff compromise also causes instablity and usually develops as a result of tuberosity compromise. Preventing this problem requires secure fixation and proper positioning of the tuberosity. If the tuberosity becomes detached, particularly in the early postoperative period, instability often can result. Detachment of the lesser tuberosity compromises

Detachment of the greater tuberosity can result in significant superior and anterior instability. Although posterior instability can occur, it is less common. Factors that predispose patients to tuberosity detachment are inadequate tuberosity fixation and noncompliance with the postoperative rehabilitation. Secure tuberosity fixation and reattachment using the priciples (transverse, longitudinal, and cerclage fixation) will decrease the risk of fixation failure. A supervised, structured rehabilitaion program also can limit the potential for patient noncompliance. The treatment of instability following tuberosity failure can be difficult. If detachment is identified early, reattachment should be considered. Tuberositiy detachment identified more than 6 months after surgery is more probelmatic. Mobilization and attachment of tuberosities can be quite difficult at this time. If the patient reports significant pain and demonstrates instability, the revision surgery,

Tuberosity nonunion is another significant complication following hemiarthroplasty. The factors that predispose patients to nonunion are related to the method of reattachment, particularly the ability to obtain proper reduction and secure fixation. The quality of bone and soft tissue also affect fixation. The significance of tuberosity nonunion can vary, but generally relates to the degree of migration and displacement. Limited amounts of migration and displacement frequently result in weakness and limited motion but not instability. With significant displacement, the patient will demonstrate weakness and limited motion, as well as instability and pain. The best approach to prevent tuberosity

Malunion of the greater or lesser tuberosity can occur, although probably with less frequency than nonunion. Malunion usually occurs as a result of either inadequate reduction at the time of surgery or inadequate fixation, which allows migration of the fragment with healing into a malunited position. Thus, proper positioning of the tuberosity

particularly in the absense of mataphyseal bony support (Young et al 2010).

anterior support and can result in anterior instability (Young et al 2010).

possibly to a reverse shoulder arthroplasty, may be necessary.

nonunion is use of an optimal method of reattachment.

2000).

has been associated with a poor functional result. The best range of motion has been reported to occur if the tuberosity is between 10 and 16 mm below the humeral head. Although these results differ somewhat, a nonanatomic final positiion of the tuberosity generally is believed to interfere with rotator cuff function and compromise range of motion and function. Lesser tuberosity malunion has received much less attention as a factir affecting outcome and does not appear to be as significant as greater tuberosity position (Zuckerman & Sajadi 2007).

Studying the clinical and radiologic parameters that can explain unsatisfactory results, final tuberosity malposition correlates with unsatisfactory results as well as superior migration of the prosthesis, poor position of the greater tuberosity and women over age 75 years (likely with osteopenic bone) (Boileau et al 2002).

At least five compelling reasons exist to reattach the tuberosities and obtain bone healing when performing a reverse shoulder prosthesis: 1) humeral length is restored and thus the deltoid is tensioned optimally; 2) joint stability is improved as a function of the restored humeral length and reconstructed anterior and posterior soft tissue walls; 3) the risk of of infection is reduced as the subacromial dead-space is minimised and the surrounding softtissues are better vascularised. 4) better primary implant stability reduces the probability of humeral implant loosening and 5) active (specifically external) rotation is restored, crucial for activities of daily living in elderly patients (Boileau et al 2010).

### **3.4 Avoiding pitfalls and complications**

Complications following hemiarthroplasty for acute proximal humerus fractures include infection, neurologic injury, preiprosthetic fracture, instability, tuberosity malunion and nonunion, rotator cuff tear, heterotopic ossification, glenoid erosion, and stiffness. Although the incidence of any specific complication is relatively low, the cumulative incidence represents at least 15%.

The incience of infection and wound healing problems is about 4% and includes acute postoperative infections and subacute delayed presentations within 6 months of the procedure. Factors that increase the risk of infection include the need for a second operation performed within a short period of time and a compromise immune system. Preventing infection requires meticulous attention to surgical preparation and drapping, particularly because of the potential contamination from the axilla. Perioperative antibiotics are indicated. Meticulous handling of soft tissues also is important. The fact that these injures occur more commonly in enderly patients whose tissues are more sensitive to injury and surgery further emphasizes its importance. If wound problems develop early in the postoperative course, treatment should be aggresive, including additional antibiotics and surgical debridement, if necessary (Young et al 2010).

Instability following hemiarthroplasty also can be a significant problem. The definition of instability varies widely, which affects the reported incidence of this problem. Several factors predispose patients to the development of instability, including component malposition, rotator cuff compromise, and tuberosity problems. Of these, component malposition is a critically important predisposing factor. Instability may result if the humeral component is placed too high or too low, resulting in secondary impingement or poor soft-tissue tension, respectively. Improper placement of the component in excessive anteversion or retroversion may lead to dislocation and tuberosity failure (Voos et al 2010).

has been associated with a poor functional result. The best range of motion has been reported to occur if the tuberosity is between 10 and 16 mm below the humeral head. Although these results differ somewhat, a nonanatomic final positiion of the tuberosity generally is believed to interfere with rotator cuff function and compromise range of motion and function. Lesser tuberosity malunion has received much less attention as a factir affecting outcome and does not appear to be as significant as greater tuberosity

Studying the clinical and radiologic parameters that can explain unsatisfactory results, final tuberosity malposition correlates with unsatisfactory results as well as superior migration of the prosthesis, poor position of the greater tuberosity and women over age 75 years (likely

At least five compelling reasons exist to reattach the tuberosities and obtain bone healing when performing a reverse shoulder prosthesis: 1) humeral length is restored and thus the deltoid is tensioned optimally; 2) joint stability is improved as a function of the restored humeral length and reconstructed anterior and posterior soft tissue walls; 3) the risk of of infection is reduced as the subacromial dead-space is minimised and the surrounding softtissues are better vascularised. 4) better primary implant stability reduces the probability of humeral implant loosening and 5) active (specifically external) rotation is restored, crucial

Complications following hemiarthroplasty for acute proximal humerus fractures include infection, neurologic injury, preiprosthetic fracture, instability, tuberosity malunion and nonunion, rotator cuff tear, heterotopic ossification, glenoid erosion, and stiffness. Although the incidence of any specific complication is relatively low, the cumulative incidence

The incience of infection and wound healing problems is about 4% and includes acute postoperative infections and subacute delayed presentations within 6 months of the procedure. Factors that increase the risk of infection include the need for a second operation performed within a short period of time and a compromise immune system. Preventing infection requires meticulous attention to surgical preparation and drapping, particularly because of the potential contamination from the axilla. Perioperative antibiotics are indicated. Meticulous handling of soft tissues also is important. The fact that these injures occur more commonly in enderly patients whose tissues are more sensitive to injury and surgery further emphasizes its importance. If wound problems develop early in the postoperative course, treatment should be aggresive, including additional antibiotics and

Instability following hemiarthroplasty also can be a significant problem. The definition of instability varies widely, which affects the reported incidence of this problem. Several factors predispose patients to the development of instability, including component malposition, rotator cuff compromise, and tuberosity problems. Of these, component malposition is a critically important predisposing factor. Instability may result if the humeral component is placed too high or too low, resulting in secondary impingement or poor soft-tissue tension, respectively. Improper placement of the component in excessive anteversion or retroversion may lead to dislocation and tuberosity failure

position (Zuckerman & Sajadi 2007).

with osteopenic bone) (Boileau et al 2002).

**3.4 Avoiding pitfalls and complications** 

surgical debridement, if necessary (Young et al 2010).

represents at least 15%.

(Voos et al 2010).

for activities of daily living in elderly patients (Boileau et al 2010).

If the component is placed in an incorrect amount of version or if humeral length is not properly restored, the risk of instability is greater. Careful attention to positioning the component intraoperatively and managining that position during cementing is essential. Inserting the component in proper version requires the use of consistent landmarks. Obtaining proper version and length during cementing can be difficult; therefore, we find the use of intraoperative fracture jigs to be beneficial. Component malposition can be prevented if a reliable method to obtain and mantain malposition during insertion is used. We believe that cemented fixation of these components is mandatory to mantain position, particularly in the absense of mataphyseal bony support (Young et al 2010).

The so-called ''unhappy triad,'' involves prosthesis with excessive height and retroversion and the greater tuberosity is positioned too low. This combination was frequently associated with poor functional results and persistent pain and stiffness. Studies have also demonstrated that acute reconstruction (less than four weeks after the injury) results in better functional outcomes because of the ease of tuberosity reconstruction (Boileau et al 2000).

Rotator cuff compromise also causes instablity and usually develops as a result of tuberosity compromise. Preventing this problem requires secure fixation and proper positioning of the tuberosity. If the tuberosity becomes detached, particularly in the early postoperative period, instability often can result. Detachment of the lesser tuberosity compromises anterior support and can result in anterior instability (Young et al 2010).

Detachment of the greater tuberosity can result in significant superior and anterior instability. Although posterior instability can occur, it is less common. Factors that predispose patients to tuberosity detachment are inadequate tuberosity fixation and noncompliance with the postoperative rehabilitation. Secure tuberosity fixation and reattachment using the priciples (transverse, longitudinal, and cerclage fixation) will decrease the risk of fixation failure. A supervised, structured rehabilitaion program also can limit the potential for patient noncompliance. The treatment of instability following tuberosity failure can be difficult. If detachment is identified early, reattachment should be considered. Tuberositiy detachment identified more than 6 months after surgery is more probelmatic. Mobilization and attachment of tuberosities can be quite difficult at this time. If the patient reports significant pain and demonstrates instability, the revision surgery, possibly to a reverse shoulder arthroplasty, may be necessary.

Tuberosity nonunion is another significant complication following hemiarthroplasty. The factors that predispose patients to nonunion are related to the method of reattachment, particularly the ability to obtain proper reduction and secure fixation. The quality of bone and soft tissue also affect fixation. The significance of tuberosity nonunion can vary, but generally relates to the degree of migration and displacement. Limited amounts of migration and displacement frequently result in weakness and limited motion but not instability. With significant displacement, the patient will demonstrate weakness and limited motion, as well as instability and pain. The best approach to prevent tuberosity nonunion is use of an optimal method of reattachment.

Malunion of the greater or lesser tuberosity can occur, although probably with less frequency than nonunion. Malunion usually occurs as a result of either inadequate reduction at the time of surgery or inadequate fixation, which allows migration of the fragment with healing into a malunited position. Thus, proper positioning of the tuberosity

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 561

and infection (eight cases) were the most common complications among the 199 shoulders that were followed for two years or were revised prior to the minimum two-year follow-up. Patients who received the reverse prosthesis at the time of a revision arthroplasty had a higher complication rate than did those who received the reverse prosthesis at the time of a primary arthroplasty. The most common complications were dislocation (fifteen cases; prevalence, 7.5%) and infection (eight cases; prevalence, 4.0%). Glenoid fractures, postoperative humeral fractures, symptomatic hardware, musculocutaneous nerve palsy, radial nerve palsy, glenoid sphere loosening, and glenoid base loosening also occurred in

To evaluate functional outcome after hemiarthroplasty for displaced proximal humeral fractures and to review whether prosthesis type, intraoperative technique or previous ipsilateral shoulder surgery could affect the outcome, Fallatah et al reviewed the medical records and radiographs of patients who had undergone hemiarthroplasty for proximal humeral fractures between 1992 and 2000. They concluded that soft tissue status and operative technique played an important role in late postoperative pain and range of motion. Hemiarthroplasty after failed open reduction and internal fixation is associated with

In the retrospective study of Gallinet D et al, forty patients were treated by shoulder replacement for three- or four-part displaced fractures of the proximal humerus between 1996 and 2004. Twenty-one had a hemiarthroplasty and 19 were treated by reverse prosthesis. The reverse prosthesis group showed better results in terms of abduction, anterior elevation and Constant score. Rotation was better in the hemiarthroplasty group. They concluded that in three- or four-part displaced proximal humerus fracture, arthroplasty did not ensure recovery of pretrauma shoulder function. Management is therefore to be decided in terms of outcome predictability and rapid recovery of daily

Hemiarthroplasty can provide good functional results, but depends on tuberosity union quality and this often necessitates a prolonged immobilization. Reverse prostheses provide reliable, rapid and predictable results in terms of abduction, anterior elevation and pain relief, but impaired rotation; this impacts quality of life and long-term implant durability

Reverse prostheses should thus prove advantageous in the treatment of complex fractures of the proximal humerus if these two drawbacks can be resolved and at present seem indicated

Compito et al reviewed the important factors for a successful outcome, including gentle soft tissue technique, secure placement of the prosthesis with proper version and height, secure tuberosity reconstruction, meticulous rotator cuff repair, and a motivated patient who is able to understand and perform the rigorous postoperative rehabilitation. Unsatisfactory results are associated with tuberosity detachment, prosthetic loosening, inadequate or noncompliant rehabilitation, preoperative nerve injury, humeral malposition, dislocation,

On the basis of the current literature, Voos et al list arthroplasties for the treatment of complex proximal humeral fractures in descending order with regard to their clinical success as follows: (1) hemiarthroplasty in a patient with reconstructible tuberosities, (2) reverse total shoulder arthroplasty in a patient with reconstructible tuberosities, (3) reverse

on condition that the patient is no younger than 70 years of age (Gallinet et al 2009).

deep infection, and ectopic hone formation (Compito et al 1994).

five or fewer cases each (Wall & Walch 2007).

comfort for elderly patients (Gallinet et al 2009).

inferior results (Fallatah et al 2008).

(glenoid notching).

intraoperatively is mandatory to avoid these problems. If necessary, intraoperative radiographs should be obtained to confirm the position. Radiographs also should be obtained early in the postoperative period to ensure that migration has not occurred. Malunion of the greater tuberosity is a much more significant problem than that of the lesser tuberosity. Posterior or superior displacement of the greater tuberosity restricts motion and can be a source of pain. Treatment of tuberosity malunion depends on functional significance. If significant pain and limited motion can be attributed to tuberosity malunion, surgical management consisting of osteotomy, mobilization, and reattachment to a more anatomic position can be considered. If the component is not in an optimal position, the component revision may be necessary. These procedures tend to be difficult and, clearly, the most effective treatment of tuberosity malunion is prevention.

Heterotopic ossification following hemiarthroplasty for acute fractures is relatively common, although it generally is not clinically significant. Small areas of heterotopic ossification an reactive bone can develop, but these generally do not interfere with function or compromise outcomes. However, more extensive ossification, particularly in the subacromial space, or bone bridging from the acromion to the proximal humerus can be significant. The factors that predispose to clinically heterotopic ossification include high-energy injuries (fracture-dislocations) and delays in surgery longer than 10 to 14 days after the acute injury. Heterotopic ossification also can develop when the procedure is performed after an early failure of internal fixation. The second procedure, particularly when it is performed 2 to 4 weeks after the initial procedure, carries a signinficant increased risk of heterotopic ossification. Whenever possible, it is important to take measures to prevent the formation of heterotopic bone. At the time of the initial surgery, meticulous technique to minimize soft-tissue trauma is important. The timing of surgery also is important. Whenever possible, the "at risk" period should be avoided. For those patients who are felt to be at high risk for heterotopic bone development, prophylactic measures can be considered, including anti-inlammatory medications postoperatively and/or the use of single-dose radiation therapy. The use of preventive measures has to be balanced with the potential to interfer with tuberosity healing and should be individualized for each patient (Young et al 2010).

Plausinis et al reported the complicationes that took place after humeral head replacement and included infection, neurologic injury, intraoperative fracture, instability, tuberosity malunion and nonunion, rotator cuff tear, heterotopic ossification, glenoid erosion, and stiffness. When technical factors such as tuberosity malunion or component malpositioning are considered as postoperative complications, the incidence of complications is relatively high (Plausinis et al 2005).

Cazeneuve et al described the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16) in which the mean Constant score was 58.5 and was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years' follow-up (Cazeneuve et al 2010).

Wall et al reported a series of 186 with 191 retained reverse total shoulder arthroplasty prostheses who were followed for an average of 39.9 months. Overall, the average Constant score improved from 23 points before surgery to 60 points at the time of follow-up and 173 of the 186 patients were satisfied or very satisfied with the result. Dislocation (fifteen cases)

intraoperatively is mandatory to avoid these problems. If necessary, intraoperative radiographs should be obtained to confirm the position. Radiographs also should be obtained early in the postoperative period to ensure that migration has not occurred. Malunion of the greater tuberosity is a much more significant problem than that of the lesser tuberosity. Posterior or superior displacement of the greater tuberosity restricts motion and can be a source of pain. Treatment of tuberosity malunion depends on functional significance. If significant pain and limited motion can be attributed to tuberosity malunion, surgical management consisting of osteotomy, mobilization, and reattachment to a more anatomic position can be considered. If the component is not in an optimal position, the component revision may be necessary. These procedures tend to be difficult and, clearly, the

Heterotopic ossification following hemiarthroplasty for acute fractures is relatively common, although it generally is not clinically significant. Small areas of heterotopic ossification an reactive bone can develop, but these generally do not interfere with function or compromise outcomes. However, more extensive ossification, particularly in the subacromial space, or bone bridging from the acromion to the proximal humerus can be significant. The factors that predispose to clinically heterotopic ossification include high-energy injuries (fracture-dislocations) and delays in surgery longer than 10 to 14 days after the acute injury. Heterotopic ossification also can develop when the procedure is performed after an early failure of internal fixation. The second procedure, particularly when it is performed 2 to 4 weeks after the initial procedure, carries a signinficant increased risk of heterotopic ossification. Whenever possible, it is important to take measures to prevent the formation of heterotopic bone. At the time of the initial surgery, meticulous technique to minimize soft-tissue trauma is important. The timing of surgery also is important. Whenever possible, the "at risk" period should be avoided. For those patients who are felt to be at high risk for heterotopic bone development, prophylactic measures can be considered, including anti-inlammatory medications postoperatively and/or the use of single-dose radiation therapy. The use of preventive measures has to be balanced with the potential to interfer with tuberosity healing and should be

Plausinis et al reported the complicationes that took place after humeral head replacement and included infection, neurologic injury, intraoperative fracture, instability, tuberosity malunion and nonunion, rotator cuff tear, heterotopic ossification, glenoid erosion, and stiffness. When technical factors such as tuberosity malunion or component malpositioning are considered as postoperative complications, the incidence of complications is relatively

Cazeneuve et al described the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16) in which the mean Constant score was 58.5 and was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of

Wall et al reported a series of 186 with 191 retained reverse total shoulder arthroplasty prostheses who were followed for an average of 39.9 months. Overall, the average Constant score improved from 23 points before surgery to 60 points at the time of follow-up and 173 of the 186 patients were satisfied or very satisfied with the result. Dislocation (fifteen cases)

most effective treatment of tuberosity malunion is prevention.

individualized for each patient (Young et al 2010).

the baseplate at 12 years' follow-up (Cazeneuve et al 2010).

high (Plausinis et al 2005).

and infection (eight cases) were the most common complications among the 199 shoulders that were followed for two years or were revised prior to the minimum two-year follow-up. Patients who received the reverse prosthesis at the time of a revision arthroplasty had a higher complication rate than did those who received the reverse prosthesis at the time of a primary arthroplasty. The most common complications were dislocation (fifteen cases; prevalence, 7.5%) and infection (eight cases; prevalence, 4.0%). Glenoid fractures, postoperative humeral fractures, symptomatic hardware, musculocutaneous nerve palsy, radial nerve palsy, glenoid sphere loosening, and glenoid base loosening also occurred in five or fewer cases each (Wall & Walch 2007).

To evaluate functional outcome after hemiarthroplasty for displaced proximal humeral fractures and to review whether prosthesis type, intraoperative technique or previous ipsilateral shoulder surgery could affect the outcome, Fallatah et al reviewed the medical records and radiographs of patients who had undergone hemiarthroplasty for proximal humeral fractures between 1992 and 2000. They concluded that soft tissue status and operative technique played an important role in late postoperative pain and range of motion. Hemiarthroplasty after failed open reduction and internal fixation is associated with inferior results (Fallatah et al 2008).

In the retrospective study of Gallinet D et al, forty patients were treated by shoulder replacement for three- or four-part displaced fractures of the proximal humerus between 1996 and 2004. Twenty-one had a hemiarthroplasty and 19 were treated by reverse prosthesis. The reverse prosthesis group showed better results in terms of abduction, anterior elevation and Constant score. Rotation was better in the hemiarthroplasty group. They concluded that in three- or four-part displaced proximal humerus fracture, arthroplasty did not ensure recovery of pretrauma shoulder function. Management is therefore to be decided in terms of outcome predictability and rapid recovery of daily comfort for elderly patients (Gallinet et al 2009).

Hemiarthroplasty can provide good functional results, but depends on tuberosity union quality and this often necessitates a prolonged immobilization. Reverse prostheses provide reliable, rapid and predictable results in terms of abduction, anterior elevation and pain relief, but impaired rotation; this impacts quality of life and long-term implant durability (glenoid notching).

Reverse prostheses should thus prove advantageous in the treatment of complex fractures of the proximal humerus if these two drawbacks can be resolved and at present seem indicated on condition that the patient is no younger than 70 years of age (Gallinet et al 2009).

Compito et al reviewed the important factors for a successful outcome, including gentle soft tissue technique, secure placement of the prosthesis with proper version and height, secure tuberosity reconstruction, meticulous rotator cuff repair, and a motivated patient who is able to understand and perform the rigorous postoperative rehabilitation. Unsatisfactory results are associated with tuberosity detachment, prosthetic loosening, inadequate or noncompliant rehabilitation, preoperative nerve injury, humeral malposition, dislocation, deep infection, and ectopic hone formation (Compito et al 1994).

On the basis of the current literature, Voos et al list arthroplasties for the treatment of complex proximal humeral fractures in descending order with regard to their clinical success as follows: (1) hemiarthroplasty in a patient with reconstructible tuberosities, (2) reverse total shoulder arthroplasty in a patient with reconstructible tuberosities, (3) reverse

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 563

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[16] Frankle M, Siegal S, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral

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total shoulder arthroplasty in a patient without reconstructible tuberosities, and (4) hemiarthroplasty in a patient without reconstructible tuberosities (Voos et al 2010).

This review covers the indications, technique, results, and complications associated with the use of prostheses for proximal humeral fractures. Meticulous technique, especially in regards to tuberosity fixation, is necessary for successful reconstruction. The use of the Reverse Total Shoulder prosthesis is in evolution but does offer exciting options in the management of these difficult patients (Voos et al 2010).

### **4. References**


total shoulder arthroplasty in a patient without reconstructible tuberosities, and (4)

This review covers the indications, technique, results, and complications associated with the use of prostheses for proximal humeral fractures. Meticulous technique, especially in regards to tuberosity fixation, is necessary for successful reconstruction. The use of the Reverse Total Shoulder prosthesis is in evolution but does offer exciting options in the

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[8] Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the

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[11] Demirhan M, Kilicoglu O, Altinel L, Eralp L, Akalin Y. Prognostic factors in prosthetic

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Shoulder Fracture-Prosthesis for the treatment of proximal humeral fractures in

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.

replacement for acute proximal humerus fractures. J Orthop Trauma

hemiarthroplasty in a patient without reconstructible tuberosities (Voos et al 2010).

management of these difficult patients (Voos et al 2010).

**4. References** 

2008;17(2):202-9.

2009;19:216-219.

1990:871-927.

109.

2007 Apr;89(4):516-20.

2003;17(3):181-189.


**26** 

*Australia* 

**Postoperative Therapy for** 

Nicola Massy-Westropp

**Metacarpophalangeal Arthroplasty** 

Since the earliest metacarpophalangeal (MCP) arthroplasties in the 1950s, numerous resurfacing and excisional arthroplasties, and a greater choice of surgical tools and techniques to implant the prostheses have become available. Of the excisional arthroplasties, one-piece and two-piece hinge designs, constrained by screws or unconstrained, cemented and non-cemented, have been designed (1) Surgeons now perform these procedures as day surgery, and leave as much original bone as possible in the likelihood of replacing the

At the time of surgery, synovectomy and soft-tissue balancing procedures are often performed to increase lateral joint stability or enhance the biomechanical advantage of the tendons around the operated joint. These procedures may necessitate post-operative immobilisation, specific joint positioning and strict motion protocols to achieve the best soft

The efficacy of postoperative therapy regimens also requires research, as they affect patient outcome, and are time-consuming and expensive. The aim of this review is to determine which postoperative regimen are most effective in achieving freedom from pain and function, and if any particular regimen is best suited to a specific prosthesis or soft-tissue

For inclusion in this review, studies had to evaluate the efficacy of a post-arthroplasty regimen for patients who had metacarpophalangeal or joint arthroplasty. Preferred study designs were metanalyses, systematic reviews, and randomised controlled trials, but all published literature except expert opinion was accepted. Patients may have received any type of implant and soft-tissue procedure, due to rheumatoid arthritis, osteoarthritis or

Electronic databases searched were the Cochrane Musculoskeletal Disease Group Register, The Cochrane Library of Systematic review, Google Scholar, and Scopus. Manual searches included of the Journal of Hand Therapy, Hand Therapy and the Journal of Arthroplasty. Search terms in all combinations included 'joint replacement, hand, wrist metacarpophalangeal, arthroplasty, rehabilitation, post-operative, occupational therapy, physical therapy'. The search included papers from 1990 onward, aiming to find research

about currently used prostheses and not prostheses of older designs and materials.

tissue range of motion and stability around the prosthesis (2-6).

**1. Introduction** 

**2. Method** 

trauma.

prosthesis as the patient ages.

balancing procedure at the time of surgery.

*School of Health Sciences, University of South Australia* 


Nicola Massy-Westropp

*School of Health Sciences, University of South Australia Australia* 
