**2.4 Control of fracture**

The first step in controlling the 4-part proximal humerus fracture is to control the tuberosities. The lesser tuberosity is displaced medially by the pull of the subscapularis

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 543

supraspinatus tendon. The remainder of the supraspinatus as well as the entire infraspinatus and teres minor tendons will be attached to the posterior fragment. Splitting the supraspinatus in line with its fibers to the level of the glenoid now allows exposure of

The humeral head is now removed and placed on the back table where it can be measured in terms of height and diameter. (Figure 9) Any missing fragments from the humeral head are typically still connected to the tuberosities and must be removed to allow adequate reduction of these tuberosities under the prosthetic humeral head. Removal of these portions of the humeral head is necessary but debulking of the tuberosity fragments is contraindicated as this may compromise tuberosity healing and positioning. The humeral head is also carefully inspected to determine the amount of calcar attached medially. The size of this fragment is indicative of the amount of missing shaft medially and will help determine the exact positioning of the prosthesis. The prosthetic humeral head should be positioned superior to the shaft a distance equal to the amount of the calcar bone left attached to the humeral head. Placement of the humeral head directly onto the humeral shaft ignoring the size of this calcar fragment will result in positioning of the head too low relative to the shaft. All cancellous bone in the humeral head can now be harvested and

Adequate prosthetic selection is determined by measuring the humeral head and canal. The proximal humeral shaft can be delivered into the operative site by extension, adduction and external rotation of the arm and placement of the elbow onto the short arm board. This allows access to the proximal humeral canal which can be measured with reamers. Minimal reaming is required. If there is no significant shaft comminution associated with the fracture, a standard length prosthetic stem on the order of 130 mm is adequate and a long stem prosthesis is not required. A prosthetic system which allows use of a narrow stem is preferred as this will allow room for bone grafting and tuberosity reduction and healing. Prostheses with a broad proximal collar often do not allow

the glenoid as well as the humeral head.

Fig. 9.

**2.5 Prosthetic selection** 

used for bone grafting of the tuberosities prior to fixation.

while the greater tuberosity is displaced posterosuperiorly by the pull of the infraspinatus and teres minor muscles. Heavy nonabsorbable sutures are passed through the subscapularis tendon to control the lesser tuberosity and through the infraspinatus tendon to control the greater tuberosity. (Figure 8) A bone hook or clamp may be necessary to reduce the greater tuberosity so that a suture can be passed through the cuff tendon. Abduction of the humerus relaxes the deltoid and assists with exposure of the greater tuberosity. Sutures are not placed through the greater tubersoity itself as bone quality may be poor and this will lead to further comminution. The rotator cuff tendon is often stronger than the bone itself and should be utilized for both mobilization and later fixation. The fracture line between the tuberosities is followed up to the rotator cuff. The rotator cuff can then be split in line with its fibers in continuity with this fracture line. This will leave a small strip of supraspinatus tendon attached to the anterior fragment. This fragment includes the lesser tuberosity, bicipital groove, and a small portion of the greater tuberosity. Attached to it are the subscapularis tendon, the rotator interval, and a small strip of the

Fig. 8.

supraspinatus tendon. The remainder of the supraspinatus as well as the entire infraspinatus and teres minor tendons will be attached to the posterior fragment. Splitting the supraspinatus in line with its fibers to the level of the glenoid now allows exposure of the glenoid as well as the humeral head.

The humeral head is now removed and placed on the back table where it can be measured in terms of height and diameter. (Figure 9) Any missing fragments from the humeral head are typically still connected to the tuberosities and must be removed to allow adequate reduction of these tuberosities under the prosthetic humeral head. Removal of these portions of the humeral head is necessary but debulking of the tuberosity fragments is contraindicated as this may compromise tuberosity healing and positioning. The humeral head is also carefully inspected to determine the amount of calcar attached medially. The size of this fragment is indicative of the amount of missing shaft medially and will help determine the exact positioning of the prosthesis. The prosthetic humeral head should be positioned superior to the shaft a distance equal to the amount of the calcar bone left attached to the humeral head. Placement of the humeral head directly onto the humeral shaft ignoring the size of this calcar fragment will result in positioning of the head too low relative to the shaft. All cancellous bone in the humeral head can now be harvested and used for bone grafting of the tuberosities prior to fixation.

542 Recent Advances in Arthroplasty

while the greater tuberosity is displaced posterosuperiorly by the pull of the infraspinatus and teres minor muscles. Heavy nonabsorbable sutures are passed through the subscapularis tendon to control the lesser tuberosity and through the infraspinatus tendon to control the greater tuberosity. (Figure 8) A bone hook or clamp may be necessary to reduce the greater tuberosity so that a suture can be passed through the cuff tendon. Abduction of the humerus relaxes the deltoid and assists with exposure of the greater tuberosity. Sutures are not placed through the greater tubersoity itself as bone quality may be poor and this will lead to further comminution. The rotator cuff tendon is often stronger than the bone itself and should be utilized for both mobilization and later fixation. The fracture line between the tuberosities is followed up to the rotator cuff. The rotator cuff can then be split in line with its fibers in continuity with this fracture line. This will leave a small strip of supraspinatus tendon attached to the anterior fragment. This fragment includes the lesser tuberosity, bicipital groove, and a small portion of the greater tuberosity. Attached to it are the subscapularis tendon, the rotator interval, and a small strip of the

Fig. 8.

### **2.5 Prosthetic selection**

Adequate prosthetic selection is determined by measuring the humeral head and canal. The proximal humeral shaft can be delivered into the operative site by extension, adduction and external rotation of the arm and placement of the elbow onto the short arm board. This allows access to the proximal humeral canal which can be measured with reamers. Minimal reaming is required. If there is no significant shaft comminution associated with the fracture, a standard length prosthetic stem on the order of 130 mm is adequate and a long stem prosthesis is not required. A prosthetic system which allows use of a narrow stem is preferred as this will allow room for bone grafting and tuberosity reduction and healing. Prostheses with a broad proximal collar often do not allow

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 545

Fig. 10a.

Fig. 10b.

enough room for tuberosity reduction without debulking and compromises the healing ability of these tuberosities. Ingrowth material on the proximal stem may be beneficial to tuberosity healing. The prosthetic stem must be narrow enough to allow adequate insertion into the humerus and avoid proud placement of the prosthesis. Prosthetic humeral head size is determined by measuring the patient's humeral head at the time of surgery both in terms of height and diameter. In prosthetic systems with an offset humeral head, placement of the maximum offset is recommended posteriorly or posterosuperiorly to allow placement of the greater tuberosity under the humeral head in this location. Appropriate head sizing will help reestablish anatomic tension on the rotator cuff tendons after tuberosity repair.

### **2.6 Prosthetic positioning**

Adequate positioning of the prosthesis both in terms of height and version is critical towards the success of this procedure and in reestablishing relatively normal anatomy for the patient postoperatively. Distortion of the normal proximal humeral anatomy by displacement of the tuberosities represents a challenge for determination of proper stem and head height. This positioning is important to reestablish the normal resting length of the deltoid muscle. There are multiple options for determining adequate height for the prosthesis. The superior margin of the pectoralis insertion typically is 56 mm from the superior aspect of the greater tuberosity and is a fairly standard measurement in patients of varying sizes (Murachovsky et al 2006). This measurement will allow the surgeon to determine whether he is in the generally correct range for prosthetic height. As mentioned previously, the size of the fragment of calcar on the humeral head will indicate the height of the prosthetic head relative to the shaft. In cases in which the greater tuberosity does not have significant comminution, the greater tuberosity fragment can be interdigitated back in the "V" shaped defect just posterior to the bicipital groove. The humeral head must be placed just superior to the greater tuberosity in this location and by reducing the greater tuberosity to the shaft, the surgeon can determine proper head height. (Figure 10ª and 10b) Tension on the biceps tendon has been recommended as a guide for the prosthetic height but is less exact. The biceps can be tenodesed at this time and removed from the joint. Finally, some prosthetic systems do allow preoperative templating relative to the contralateral arm with jigs which can be utilized for determining height. These systems are often unwieldy and difficult to use. Placement of the prosthesis too low will result in inferior subluxation of the humeral head relative to the glenoid and cause weakness in elevation. Proud placement of the prosthesis will lead to overstuffing of the joint, superior subluxation, pain, and stiffness. Anatomic version of the humeral head has been generally reported between 20 and 40° of retroversion. Placing the prosthesis in less retroversion places less tension on the greater tuberosity fragment during internal rotation and may benefit healing. Version of approximately 20° is recommended for this reason and can be determined relative to the patients' forearm. In prosthetic systems with a posterior fin of the prosthesis positioned 180° from the medial calcar portion of the stem, this posterior fin should generally be located just posterior to the bicipital groove. The humeral stem is generally cemented in place to avoid subsidence and malrotation because the stabilizing effect typically afforded by the tuberosities has been lost due to the fracture.

Fig. 10a.

544 Recent Advances in Arthroplasty

enough room for tuberosity reduction without debulking and compromises the healing ability of these tuberosities. Ingrowth material on the proximal stem may be beneficial to tuberosity healing. The prosthetic stem must be narrow enough to allow adequate insertion into the humerus and avoid proud placement of the prosthesis. Prosthetic humeral head size is determined by measuring the patient's humeral head at the time of surgery both in terms of height and diameter. In prosthetic systems with an offset humeral head, placement of the maximum offset is recommended posteriorly or posterosuperiorly to allow placement of the greater tuberosity under the humeral head in this location. Appropriate head sizing will help reestablish anatomic tension on the

Adequate positioning of the prosthesis both in terms of height and version is critical towards the success of this procedure and in reestablishing relatively normal anatomy for the patient postoperatively. Distortion of the normal proximal humeral anatomy by displacement of the tuberosities represents a challenge for determination of proper stem and head height. This positioning is important to reestablish the normal resting length of the deltoid muscle. There are multiple options for determining adequate height for the prosthesis. The superior margin of the pectoralis insertion typically is 56 mm from the superior aspect of the greater tuberosity and is a fairly standard measurement in patients of varying sizes (Murachovsky et al 2006). This measurement will allow the surgeon to determine whether he is in the generally correct range for prosthetic height. As mentioned previously, the size of the fragment of calcar on the humeral head will indicate the height of the prosthetic head relative to the shaft. In cases in which the greater tuberosity does not have significant comminution, the greater tuberosity fragment can be interdigitated back in the "V" shaped defect just posterior to the bicipital groove. The humeral head must be placed just superior to the greater tuberosity in this location and by reducing the greater tuberosity to the shaft, the surgeon can determine proper head height. (Figure 10ª and 10b) Tension on the biceps tendon has been recommended as a guide for the prosthetic height but is less exact. The biceps can be tenodesed at this time and removed from the joint. Finally, some prosthetic systems do allow preoperative templating relative to the contralateral arm with jigs which can be utilized for determining height. These systems are often unwieldy and difficult to use. Placement of the prosthesis too low will result in inferior subluxation of the humeral head relative to the glenoid and cause weakness in elevation. Proud placement of the prosthesis will lead to overstuffing of the joint, superior subluxation, pain, and stiffness. Anatomic version of the humeral head has been generally reported between 20 and 40° of retroversion. Placing the prosthesis in less retroversion places less tension on the greater tuberosity fragment during internal rotation and may benefit healing. Version of approximately 20° is recommended for this reason and can be determined relative to the patients' forearm. In prosthetic systems with a posterior fin of the prosthesis positioned 180° from the medial calcar portion of the stem, this posterior fin should generally be located just posterior to the bicipital groove. The humeral stem is generally cemented in place to avoid subsidence and malrotation because the stabilizing effect typically

rotator cuff tendons after tuberosity repair.

afforded by the tuberosities has been lost due to the fracture.

**2.6 Prosthetic positioning** 

Fig. 10b.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 547

of motion. (Figure 16) Adequacy of reduction of the tuberosity fragments can be verified fluoroscopically. The continuity of the axillary nerve can be verified using the Tug test.

Suction drains are placed deep to the deltoid and a layered closure is performed.

Fig. 11.

#### **2.7 Tuberosity fixation**

Postoperative function is most closely tied to anatomic healing of the tuberosities. The success of tuberosity healing is directly related to the adequacy of reduction and fixation of the tuberosities at the time of surgery. Tuberosity healing is a major challenge and greater tuberosity pull off remains the most common complication of this surgery (Boileau et al 2002). The tuberosities must heal to each other and to the shaft as well as to the ingrowth material of the humeral prosthesis. A variety of fixation techniques have been reported but techniques recommended by both Frankle and Boileau have demonstrated superior biomechanical resistance to deforming forces (Boileau et al 2000, Frankle et al 2002). The tuberosities are repaired utilizing a suture technique which fixes these tuberosities to each other, to the prosthesis, and to the shaft of the humerus. The placement of these sutures and drill holes for their placement is necessary prior to cementing the humeral stem in place. Drill holes in the shaft include the one drill hole anterior to the bicipital groove, two drill holes straddling the bicipital groove, and one drill hole posterior to the bicipital groove. (Figure 11) In cases in which the "V" shaped fragment of the greater tuberosity is of adequate size, small drill holes between this fragment and the humeral shaft just posterior to the bicipital groove can be utilized for a figure of 8 reduction suture. (Figure 12) This suture does not resist deforming forces but is used for anatomic reduction of the tuberosity. #5 polyester nonabsorbable sutures are placed through the anterior drill hole and through the posterior drill hole respectively. One #5 polyester suture is passed through the holes straddling the bicipital groove in such a way that both ends of this suture pass out from the canal with a small loop of suture inside the canal. While the cement for stem fixation is curing, morcelized bone graft is packed into the proximal canal just above the cement. (Figure 13) These small fragments are fixed to the cement while the cement is setting. This creates a bony surface for healing to the tuberosities. The greater tuberosity is repaired first. One or two cerclage sutures of #5 polyester suture are placed through the rotator cuff at the bone tendon junction and around the anterior stem of the prosthesis. The #5 polyester suture from the anterior drill hole in the shaft is then passed diagonally across the prosthesis and through the rotator cuff tendon at the bone-tendon interface to fix the greater tuberosity to the shaft and to resist vertically directed deforming forces against the tuberosity. (Figure 14) The greater tuberosity is fixed to the posterior aspect of the fin on the stem just inferior to the humeral head utilizing the cerclage sutures passed around the prosthesis. The bone graft is inserted between the prosthesis and the greater tuberosity to restore bulk to the tuberosity and to assist with healing. The posterior shaft suture is then passed diagonally across the prosthesis and passed through the subscapularis tendon at the bone-tendon junction. One to two cerclage sutures between the greater tuberosity and lesser tuberosity are then used to reduce the lesser tuberosity to the stem just underneath the humeral head anterior to the prosthetic fin. Again bone graft is used as needed and the cerclage sutures are tied. The suture from the posterior shaft to the lesser tuberosity is then tied. The rotator cuff split made previously during exposure is closed using nonabsorbable figure of 8 sutures. By making that split through the supraspinatus tendon, good tissue is available for repair anteriorly and posteriorly to help resist greater tuberosity pull-off. Finally, the two suture limbs at the bicipital groove distally are passed in a figure of 8 fashion over the rotator interval and rotator cuff split to firmly repair these to each other and to the shaft. (Figure 15) The stability and strength of the repair is then tested by taking the arm through gentle range

Postoperative function is most closely tied to anatomic healing of the tuberosities. The success of tuberosity healing is directly related to the adequacy of reduction and fixation of the tuberosities at the time of surgery. Tuberosity healing is a major challenge and greater tuberosity pull off remains the most common complication of this surgery (Boileau et al 2002). The tuberosities must heal to each other and to the shaft as well as to the ingrowth material of the humeral prosthesis. A variety of fixation techniques have been reported but techniques recommended by both Frankle and Boileau have demonstrated superior biomechanical resistance to deforming forces (Boileau et al 2000, Frankle et al 2002). The tuberosities are repaired utilizing a suture technique which fixes these tuberosities to each other, to the prosthesis, and to the shaft of the humerus. The placement of these sutures and drill holes for their placement is necessary prior to cementing the humeral stem in place. Drill holes in the shaft include the one drill hole anterior to the bicipital groove, two drill holes straddling the bicipital groove, and one drill hole posterior to the bicipital groove. (Figure 11) In cases in which the "V" shaped fragment of the greater tuberosity is of adequate size, small drill holes between this fragment and the humeral shaft just posterior to the bicipital groove can be utilized for a figure of 8 reduction suture. (Figure 12) This suture does not resist deforming forces but is used for anatomic reduction of the tuberosity. #5 polyester nonabsorbable sutures are placed through the anterior drill hole and through the posterior drill hole respectively. One #5 polyester suture is passed through the holes straddling the bicipital groove in such a way that both ends of this suture pass out from the canal with a small loop of suture inside the canal. While the cement for stem fixation is curing, morcelized bone graft is packed into the proximal canal just above the cement. (Figure 13) These small fragments are fixed to the cement while the cement is setting. This creates a bony surface for healing to the tuberosities. The greater tuberosity is repaired first. One or two cerclage sutures of #5 polyester suture are placed through the rotator cuff at the bone tendon junction and around the anterior stem of the prosthesis. The #5 polyester suture from the anterior drill hole in the shaft is then passed diagonally across the prosthesis and through the rotator cuff tendon at the bone-tendon interface to fix the greater tuberosity to the shaft and to resist vertically directed deforming forces against the tuberosity. (Figure 14) The greater tuberosity is fixed to the posterior aspect of the fin on the stem just inferior to the humeral head utilizing the cerclage sutures passed around the prosthesis. The bone graft is inserted between the prosthesis and the greater tuberosity to restore bulk to the tuberosity and to assist with healing. The posterior shaft suture is then passed diagonally across the prosthesis and passed through the subscapularis tendon at the bone-tendon junction. One to two cerclage sutures between the greater tuberosity and lesser tuberosity are then used to reduce the lesser tuberosity to the stem just underneath the humeral head anterior to the prosthetic fin. Again bone graft is used as needed and the cerclage sutures are tied. The suture from the posterior shaft to the lesser tuberosity is then tied. The rotator cuff split made previously during exposure is closed using nonabsorbable figure of 8 sutures. By making that split through the supraspinatus tendon, good tissue is available for repair anteriorly and posteriorly to help resist greater tuberosity pull-off. Finally, the two suture limbs at the bicipital groove distally are passed in a figure of 8 fashion over the rotator interval and rotator cuff split to firmly repair these to each other and to the shaft. (Figure 15) The stability and strength of the repair is then tested by taking the arm through gentle range

**2.7 Tuberosity fixation** 

of motion. (Figure 16) Adequacy of reduction of the tuberosity fragments can be verified fluoroscopically. The continuity of the axillary nerve can be verified using the Tug test. Suction drains are placed deep to the deltoid and a layered closure is performed.

Fig. 11.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 549

Fig. 13.

Fig. 12.

Fig. 13.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 551

Fig. 15.

Fig. 14.

Fig. 14.

Fig. 15.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 553

the management of these complex fractures. The technique of reverse prosthesis in this situation is relatively straightforward (Wall & Walch 2007). The dissection up to removal of the humeral head is identical to that described previously for standard humeral head replacement. The deltopectoral approach is preferred over the superior approach for this indication as it permits easier rehabilitation and allows the surgeon to address any distal humeral shaft comminution that may be present. The exposure of the glenoid is easier than usual as the tuberosities are displaced away from the shaft and the glenoid can be clearly visualized at the time of surgery. The capsule and labrum are released from the glenoid to allow clear exposure of the glenoid rim. The glenoid is reamed according to the specifications of the particular prosthesis. The glenoid baseplate is placed slightly inferiorly and inclined caudally to help avoid notching of the lateral scapular border. Standard placement of the glenosphere is indicated. Humeral stem placement is dictated by soft tissue tension as in standard cases. Minimal or no pistoning of the stem relative to glenosphere should be present with adequate tension across the deltoid. Tension on the tuberosities will also influence the determination of stem height. Version is generally recommended at 0-20° of retroversion but can be altered to allow for optimal tuberosity reduction. In cases in which the supraspinatus is still attached to the greater tuberosity, the tendon insertion may require release in order to mobilize the tuberosity distally enough to reach the shaft and prosthesis. Similar suture fixation is recommended with cerclage sutures between the tuberosities and the prosthesis as well as the vertically aligned sutures diagonally between the shaft and the greater and lesser tuberosities. (Figure 17ª and 17**b**) Prostheses with proximal ingrowth may help tuberosity union. Tuberosity repair should decrease incidence of prosthetic instability and allow improved external rotation postoperatively. Currently limited information as to the benefits of tuberosity healing is available in this setting (Bufquin et al 2007). Following tuberosity fixation with either the reverse prosthesis or standard humeral head replacement, suction drainage in indicated to avoid hematoma formation. The deltopectoral interval is closed

Postoperative rehabilitation is geared toward allowing adequate tuberosity healing while helping the patient to regain flexibility in a reasonable and safe fashion. During the first six weeks following surgery the tuberosities are vulnerable to avulsion from active use or extreme range of motion with passive stretching. A protective ultrasling is indicated for the first six weeks following surgery holding the arm in neutral rotation to limit tension on the greater tuberosity fragment. The patient is allowed to perform gentle pendulum exercises with passive external rotation exercises utilizing a stick. Range of motion exercises of the

Once tuberosity healing can be verified radiographically, active use of the arm can be instituted. This typically occurs at approximately six weeks following surgery. Activeassisted exercises are begun in the supine position along with passive stretching under the supervision of a physical therapist. Light activities of daily living are allowed with the elbow at the side with progression of this as active function increases. Between weeks 6 and 12, exercises are characterized by gentle stretching with isometric strengthening for muscle reeducation. Beginning at 12 weeks, a resistive exercise program can be started below shoulder level with advancement to above shoulder exercises once the patient's

elbow, wrist, and fingers are encouraged with gentle active use of these joints.

and the skin is closed in a layered fashion.

strength increases.

Fig. 16.

### **2.8 Reverse prosthesis for fracture**

Indications for the use of the reverse total shoulder arthroplasty in the management of displaced proximal humerus fractures is in evolution. This prosthesis is generally not recommended in younger patients and it's use has most often been reported in patients around the age of 70. It should be considered in cases with a relatively poor prognosis with use of the humeral head replacement including elderly patients (›75), patients with pre-existing large rotator cuff tears, and patients whose fracture care has been delayed. These patients are at particular risk for poor tuberosity healing (Boileau et al 2002). Use has been spurred by variability in functional results of the humeral head replacement in

Indications for the use of the reverse total shoulder arthroplasty in the management of displaced proximal humerus fractures is in evolution. This prosthesis is generally not recommended in younger patients and it's use has most often been reported in patients around the age of 70. It should be considered in cases with a relatively poor prognosis with use of the humeral head replacement including elderly patients (›75), patients with pre-existing large rotator cuff tears, and patients whose fracture care has been delayed. These patients are at particular risk for poor tuberosity healing (Boileau et al 2002). Use has been spurred by variability in functional results of the humeral head replacement in

Fig. 16.

**2.8 Reverse prosthesis for fracture** 

the management of these complex fractures. The technique of reverse prosthesis in this situation is relatively straightforward (Wall & Walch 2007). The dissection up to removal of the humeral head is identical to that described previously for standard humeral head replacement. The deltopectoral approach is preferred over the superior approach for this indication as it permits easier rehabilitation and allows the surgeon to address any distal humeral shaft comminution that may be present. The exposure of the glenoid is easier than usual as the tuberosities are displaced away from the shaft and the glenoid can be clearly visualized at the time of surgery. The capsule and labrum are released from the glenoid to allow clear exposure of the glenoid rim. The glenoid is reamed according to the specifications of the particular prosthesis. The glenoid baseplate is placed slightly inferiorly and inclined caudally to help avoid notching of the lateral scapular border. Standard placement of the glenosphere is indicated. Humeral stem placement is dictated by soft tissue tension as in standard cases. Minimal or no pistoning of the stem relative to glenosphere should be present with adequate tension across the deltoid. Tension on the tuberosities will also influence the determination of stem height. Version is generally recommended at 0-20° of retroversion but can be altered to allow for optimal tuberosity reduction. In cases in which the supraspinatus is still attached to the greater tuberosity, the tendon insertion may require release in order to mobilize the tuberosity distally enough to reach the shaft and prosthesis. Similar suture fixation is recommended with cerclage sutures between the tuberosities and the prosthesis as well as the vertically aligned sutures diagonally between the shaft and the greater and lesser tuberosities. (Figure 17ª and 17**b**) Prostheses with proximal ingrowth may help tuberosity union. Tuberosity repair should decrease incidence of prosthetic instability and allow improved external rotation postoperatively. Currently limited information as to the benefits of tuberosity healing is available in this setting (Bufquin et al 2007). Following tuberosity fixation with either the reverse prosthesis or standard humeral head replacement, suction drainage in indicated to avoid hematoma formation. The deltopectoral interval is closed and the skin is closed in a layered fashion.

Postoperative rehabilitation is geared toward allowing adequate tuberosity healing while helping the patient to regain flexibility in a reasonable and safe fashion. During the first six weeks following surgery the tuberosities are vulnerable to avulsion from active use or extreme range of motion with passive stretching. A protective ultrasling is indicated for the first six weeks following surgery holding the arm in neutral rotation to limit tension on the greater tuberosity fragment. The patient is allowed to perform gentle pendulum exercises with passive external rotation exercises utilizing a stick. Range of motion exercises of the elbow, wrist, and fingers are encouraged with gentle active use of these joints.

Once tuberosity healing can be verified radiographically, active use of the arm can be instituted. This typically occurs at approximately six weeks following surgery. Activeassisted exercises are begun in the supine position along with passive stretching under the supervision of a physical therapist. Light activities of daily living are allowed with the elbow at the side with progression of this as active function increases. Between weeks 6 and 12, exercises are characterized by gentle stretching with isometric strengthening for muscle reeducation. Beginning at 12 weeks, a resistive exercise program can be started below shoulder level with advancement to above shoulder exercises once the patient's strength increases.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 555

Fig. 17b.

Fig. 17a.

Fig. 17a.

Fig. 17b.

Shoulder Hemiarthroplasty in Proximal Humerus Fractures 557

Complex displaced three and four-part fractures, fracture-dislocations, and fractures with a humeral head split are at risk for the development of malunion and osteonecrosis, especially after internal fixation. Shoulder hemiarthroplasty or, recently, reverse total shoulder arthroplasty is indicated for the treatment of some of these complex fractures (Voos et al

In spite of advanced patient age, tuberosity healing can be achived by reattachment and bone grafting around specific Reverse Fracture prosthesis, according to Boileau et al. Successful peri-prosthetic tuberosity healing is associated with restoration of both active

Pain relief is the most predictable outcome following hemiarthroplasty for four-part proximal humerus fractures. Many authors have supported this finding, with 61% to 97% of patients reporting complete patiens reporting pain relief. Significant resifual 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

Reports of patient satisfaction vary widely, from 58% to 92,% , in part because of the numerous scales used to mesure outcome and satisfaction. 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

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

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,

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

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

surgery within 1 week of injury seems to be associated with improved outcomes.

elevation and external rotation (Boileau et al 2010). (Figure 18)

rehabilitation and a more structurally intact rotator cuff.

**3. Results** 

2010).

**3.1 Pain relief** 

(Young et al 2010).

**3.2 Patient satisfaction** 

acceptable (Young et al 2010).

**3.3 Prognostic factors** 

confounding variable.
