**9. References**

[1] Griffith SL, Shelokov AP, Buttner-Janz K, LeMaire JP, Zeegers WS. A multicenter retrospective study of the clinical results of the LINK SB Charite intervertebral

If a CHARITÉ artificial disc were required to be revised, there would be two options available. One approach would be anterior reoperation. This would involve dissecting the retroperitoneal area and dealing with the post-op scarring and hence increased risk of great vessel damage, ureteral damage, and damage to the sympathetic nerves compared to a case without prior dissection and scarring in the retroperitoneal space. A revision allows removal, position adjustment or size change of the CHARITÉ artificial disc. The plastic core would be removed first, and then the metal endplates are separated from the bony endplates by using a chisel between them and levering away from the bone into the disc space. This would allow the placement of another artificial disc in the disc space or the conversion to a fusion. Alternately, a posterior operation with rod-screw stabilization and posterior lateral fusion could be used to fuse the lumbar segment, which would use the CHARITÉ artificial disc as an anterior load share device. As with all surgical decision making, understanding the biomechanical reasoning and etiology of clinical failure is of the utmost importance. In patients with recurring or persistent pain the characterization of the pain generator is often more important than the exact surgical technique used. Radiologic studies such as dynamic A-P and Lat x-ray and multislice CT will aid in understanding failure of the device or progression of the degenerative anatomic changes. Radiologic and provocative studies, including discography, anesthetic or negative discography, nerve root blocks, epidural injections, and

facet injections may all be utilized to identify the anatomic site of the pain generator.

The initial CHARITÉ was planned with a 2-year follow-up period. At the request of the FDA the follow-up period was extended to 5-years and the sites requested to participate in the "new" 2 to 5 year follow-up period. Multiple sites did participate in this extended reporting period and formed the basis of the 5-year CHARITÉ results. The CHARITÉ 5-year ODI and VAS results (Figure 2a and 2b respectively) were substantially the same as the 2-years follow-up results60. Despite the prospective collection of the these results, critics formulated

Overall, there were only minor differences between devices in terms of overall clinical and radiographic outcome. Significant improvements in clinical outcomes were seen with all evaluated devices, regardless of make or design. An average maintenance of motion postoperatively was described, along with relatively low rates of revision. Differences between devices were mostly apparent in complication types: one potential complication for devices with keels was vertebral body split, while devices with metal-on-metal designs could cause metallosis and ion release in the serum. As for metal-on-poly devices, degradation of the polymer core was also mentioned as a potential complication, albeit one that is not relevant for the current metal-on-poly devices. Specific emphasis was found in most of all publications on proper technique and patient selection, regardless of implant design.

[1] Griffith SL, Shelokov AP, Buttner-Janz K, LeMaire JP, Zeegers WS. A multicenter

retrospective study of the clinical results of the LINK SB Charite intervertebral

**7. Long-term follow-up of TDR patients** 

objections to these reported good results61.

Finally, arthroplasty was found to be less costly than fusion.

**8. Conclusion** 

**9. References** 

**6. Revision techniques** 

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**25** 

*1,3Spain 2USA* 

**Shoulder Hemiarthroplasty in** 

**Proximal Humerus Fractures** 

*1Orthopaedics Department, Hospital Infanta Elena, Valdemoro* 

*3Orthopaedics Department, Hospital Infanta Elena, Valdemoro* 

*2Orthopaedics Department, Peachtree Orthopaedic Clinic, Atlanta GA* 

José Hernández Enríquez, Xavier A. Duralde and Antonio J. Pérez Caballer

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

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

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

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

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

four-part proximal fractures if acceptable redution cannot be obtained.

obtained but overhead use is not typical following this surgery.

**1. Introduction** 

to one another.

reported to be consistent.

result of the muscular deforming force.

