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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 624-629

Evaluation of results of cemented modular hemiarthroplasty in comminuted fractures of the proximal humerus


Department of Orthopedics and Traumatology, Faculty of Medicine, Menoufieya University, Menoufieya, Egypt

Date of Submission17-Sep-2017
Date of Acceptance19-Nov-2017
Date of Web Publication25-Jun-2019

Correspondence Address:
Ahmed N El Barbarey
Department of Orthopedic, Faculty of Medicine, Menoufieya University, Menoufieya 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_625_17

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  Abstract 

Objective
The aim of this work was to evaluate the results of use of cemented modular hemiarthroplasty prosthesis in cases of comminuted fractures of the proximal humerus.
Background
Proximal humeral fractures account for ∼5% of all joint fractures. More than 70% of patients with these fractures are older than 60 years of age, 75% are women and most of these fractures are related to osteoporosis. Shoulder hemiarthroplasty is a method of treatment of comminuted proximal humeral fractures in which complication of fracture fixation is avoided with a restoration of the anatomy of the shoulder joint.
Materials and methods
In the period between February 2012 and February 2016, a prospective study of 20 patients with post-traumatic comminuted fracture of the proximal humerus with or without dislocation of the humeral head had been admitted to El-Menoufia University Hospital. All cases that fulfilled the inclusion criteria had been treated with cemented modular hemiarthroplasty.
Results
The age of the patients in this study range from 30 to 75 years, 14 (70%) women and six (30%) men. The shoulder range of motion in two (10%) cases had an excellent result, eight (40%) cases had good results, seven (35%) cases had fair results, and three (15%) cases had poor results. Seventeen (85%) cases were satisfied with the results and three (15%) cases were not satisfied with the procedure.
Conclusion
Shoulder hemiarthroplasty is a method of treatment of comminuted proximal humeral fractures particularly in osteoporotic bone.

Keywords: comminuted fractures, hemiarthroplasty, humeral head, range of motion, shoulder fractures


How to cite this article:
Neanaa HA, Eid TA, Ebied AM, El-Seedy AI, Hassan BZ, El Barbarey AN. Evaluation of results of cemented modular hemiarthroplasty in comminuted fractures of the proximal humerus. Menoufia Med J 2019;32:624-9

How to cite this URL:
Neanaa HA, Eid TA, Ebied AM, El-Seedy AI, Hassan BZ, El Barbarey AN. Evaluation of results of cemented modular hemiarthroplasty in comminuted fractures of the proximal humerus. Menoufia Med J [serial online] 2019 [cited 2019 Sep 20];32:624-9. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/624/260905




  Introduction Top


Of all the joints in the body, the shoulder complex has the greatest mobility. The shoulder girdle is described as having five articulations: the glenohumeral joint is the main concern in shoulder arthroplasty (GH), acromioclavicular (AC), sternoclavicular (SC), and in scapulothoracic (ST) and subdeltoid joints. The mechanics of the shoulder joint are more complex in comparison to any other joint of the body. Large arcs of motion in all planes allow the shoulder to perform a multitude of functions including push, propulsion, and hand placement[1].

Proximal humeral fractures account for ∼5% of all fractures of other joints. More than 70% of patients with these fractures are older than 60 years of age, and 75% are women. In the elderly population, most of these fractures are related to osteoporosis[1].

Proximal humeral fractures are common and have a bimodal age distribution. Fracture dislocations in younger patients result from high-energy injuries, and most surgeons attempt open reduction and internal fixation if possible. Osteoporotic fractures in elderly patients are commonly associated with minor trauma such as ground-level falls, and most are minimally displaced impacted fractures that can be treated successfully by nonoperative means. However, the optimal surgical management of comminuted fractures of the proximal humerus in elderly osteoporotic patients remains controversial, with many advocating prosthetic replacement of the humeral head. A variety of treatment techniques have been proposed, including open reduction and internal fixation with proximal humeral plates, hemiarthroplasty, and percutaneous or minimally invasive techniques such as pinning, screw osteosynthesis, and the use of intramedullary nails. However, several complications have been described in association with these techniques, such as implant failure, loss of reduction, nonunion or malunion of the fracture, impingement syndrome, and osteonecrosis of the humeral head[2].

Shoulder hemiarthroplasty is a method of treatment of comminuted proximal humeral fractures, in which complication of fracture fixation is avoided with a restoration of the anatomy of the shoulder joint[3].

The shoulder was the first human joint to be replaced with a prosthesis. Jules E. Pean, born in France in 1830, was the first one to implant shoulder prosthesis in a 37-year-old person with tuberculosis of the proximal humerus and shoulder joint. It was on the 11 March 1893 at the International Hospital in Paris. Gluck, born in Romania in 1853, made great contributions to many branches of experimental surgery at the end of the 19th century and without doubt, he was the pioneer of joint replacement and devised prostheses for many joints including the shoulder[4].

The era of shoulder replacement was developed with the pioneering work of Dr Charles S. Neer In 1953, he devised a hemiarthroplasty for fractures of the neck of the humerus. The first series of 12 cases were performed during 1953 and early 1954. By 1964, Neer had applied his technique to 54 patients[5].

The aim of the current study was to evaluate the results of cemented modular hemiarthroplasty in comminuted fractures of the proximal humerus in terms of pain improvement, improvement of range of motion, patient satisfaction, and improvement of the constant score.


  Materials and Methods Top


The study was approved by Ethics Committee of Faculty of Medicine, Menoufia University; and consent was taken from each patient.

Between the period of February 2012 and February 2013, the patients were recruited and the participants who were matching the inclusion criteria were 20 patients, and the patients has been followed until end of the study in February 2016.

Type of the study

This is an interventional, randomized, prospective study of 20 patients with post-traumatic comminuted fracture of the proximal humerus with or without dislocation of the humeral head had been admitted to El-Menoufia University Hospital. All cases that fulfilled the inclusion criteria had been treated with cemented modular hemiarthroplasty.

Inclusion criteria

Age of 30–75 years.

General conditions

Medically fit for anesthesia patient without dementia or with medically controlled chronic diseases such as diabetes mellitus or hypertension.

Fracture type

Patients have a comminuted fracture with the following criteria of the fracture: (a) avascular head, (b) osteoporotic head, (c) inability to obtain stable fixation of the fracture, and (d) split fracture of the head.

Preoperative shoulder function

Previous good shoulder function with intact rotator cuff muscles prior to the fracture with no arthritic changes of the head and the glenoid or after failed internal fixation. In cases of tuberosity nonunion or absorption or failed metal work as a broken plate or backed out screws.

Exclusion criteria

Revision cases (previously failed arthroplasty). Arthritis of the shoulder joint, infection, patients unfit for operation (medically unfit or bad investigation), and patients with neurological disorders such as  Parkinsonism More Details and cerebral palsy.

Demographic data

The age ranges from 52 to 75 years including 14 (70%) women and six (30%) men, 19 (95%) urban patients, and one (5%) rural patient, 12 (60%) housewives, two (10%) workers, two (10%) employees, two (10%) retired, one (5%) teacher, and one (5%) taxi driver; 12 (60%) cases had medical problems and eight (40%) cases had no medical problems. Preoperative control of these medical problems was done by an internal medicine consultation doctor. All (100%) cases were right handed with no left-handed cases with two cases having had the previous operation.

Mode of trauma and associated injury

Low-energy trauma was the cause of trauma in 12 (60%) cases and high-energy trauma was the cause of trauma in eight (40%) cases. One (5%) case had a trochanteric fracture which was treated by a dynamic hip screw and 19 (95%) cases have no associated injury. In 16 (80%) cases, the side affected was the right side, whereas in four (20%) cases the left side was affected.

Classification of fracture

A total of 14 (70%) cases were of four-part fracture, five (25%) cases were of three-part fracture, and one (5%) case was of two-part fracture. There were 19 (95%) cases if closed fractures and one (5%) case of open fracture which was treated by debridement of the wound at the time of trauma.

Time gap between trauma and operation

Ranged from 1 week after trauma up to 24 weeks after trauma with mean 7.75 ± 9.01.

Methods

Full preoperative assessment including clinical and radiological examination with routine investigation was done for every patient in the study and postoperative clinical and radiological were done for all patients of the study.

Preoperative patient preparation

Two units of packed red blood cells were prepared for every patient, but their use was according to the amount of blood loss [eight (40%) cases in the study needed blood transfusion]. Prophylactic antibiotic protocol: vancomycin 1 g starting at anesthesia time in addition to third generation cephalosporin for 48 h postoperatively.

Operative technique

General anesthesia was used in all cases of the study. Preparatory steps: urinary catheter was applied, the number of persons in the operative theater was kept to the minimum (seven persons: main surgeons and two assistant doctors, an anesthesia doctor, two nurses, and a technician of the medical company). Traffic in and out of the theater was minimized as much as possible by keeping the doors closed. All persons in the operative theater follow sterilization rules – shaving of the skin and axilla at the operating theater immediately before surgery to decrease the risk of infection.

Patient position

Beach chair position was done in all cases of the study.

Surgical approach

Deltopectoral approach was used in all cases. Fixation of the tuberosities: nonabsorbable sutures attached to greater and lesser tuberosities pass through the corresponding holes through the prosthesis, then with final attachment using transosseous sutures.

  1. Insertion of proper head size and reduction of the joint
  2. Tightening of the transosseous sutures was done for accurate reduction of the tuberosities
  3. Bone grafting between the tuberosities and the shaft of the humerus to allow healing of the tuberosities to the shaft of the humerus
  4. Closure of the wound in layers after application of suction drain. Skin closure using skin clips.


Operative data of study

General anesthesia was done for all cases (100%) and beach chair position was done for all cases of study (100%). Transosseous sutures of rotator cuff tendons were done to 17 (85%) cases and direct attachment of rotator cuff tendons was done for three (15%) cases. Fourteen (82.44%) cases underwent full union of greater and lesser tuberosity to the shaft of humerus, whereas three (17.6%) cases have no union of tuberosities to the shaft of the humerus. Thirteen (65%) cases underwent biceps tenodesis, whereas in seven (35%) cases no tenodesis was done. Tenodesis were done for this cases due to the rupture of biceps tendon during operation.

Intraoperative complications

All cases had no intraoperative complications during this study. The amount of blood loss and the need for blood transfusion range from 400 to 800 cm3 with a mean ± SD of 532.5 ± 90.72. Eight (40%) cases needed a blood transfusion and 12 (60%) cases did not need a blood transfusion. Only o1 U of packed red blood cells was needed for every case needed a blood transfusion with mean ± SD was 1 ± 0.000.

Rotator cuff tear

Two (10%) cases had rotator cuff tear and in 18 (90%) cases, the rotator cuff tendons had no rotator cuff tears. The tear of rotator cuff tendons was a partial tear and the repair of tendons was done with nonabsorbable sutures during reattachment of the tendons by transosseous sutures or to the prosthesis.

Operative time

Ranged from 1.5 to 2.5 h with mean ± SD of about 2.08 ± 0.34.

Statistical analysis

Results were collected, tabulated, and statistically analyzed by an IBM compatible personal computer with SPSS software package (version 20.0; IBM Corp., Armonk, New York, USA).

The type of statistical analysis done was descriptive statistics as follows:

  1. Quantitative data were presented by a mean and SD
  2. Qualitative data were presented by number and percentage.



  Results Top


This prospective study of 20 patients with post-traumatic comminuted fracture of the proximal humerus with or without dislocation of the humeral head was done at the El-Menoufia University Hospital. Cemented modular hemiarthroplasty was done for all cases. The clinical results were assessed according to constant shoulder score. All cases fulfilled the inclusion criteria. The follow-up period was 1.5 years.

Postoperative range of motion (at the end of follow-up). Flexion: the lowest range of flexion was 20° whereas the highest range of flexion was 105° with mean ± SD 76.50 ± 23.46. Abduction: the lowest range of abduction was 10° whereas the highest range of motion was 95° with mean ± SD of 52.25 ± 27.41. Extension: the lowest range of extension was 10°, whereas the highest range of extension was 45° with mean ± SD of 32.00 ± 9.92. Adduction: the lowest range of motion was 10°, whereas the highest range of motion was 40° with mean ± SD of 32.50 ± 13.52.

Constant shoulder score

Used in the evaluation of results of the study. The scoring system consists of four variables: two subjective variables (total score: 35 points) and two objective variables (total score: 65 points). The results were analyzed and result divided into four grades: more than 30 poor, 21–30 fair, 11–20 good, and less than 11 excellent. P value of 0.860 was not significant [Table 1].
Table 1: Relationship between constant score and medical history of patients, mode trauma, type of arthroplasty, and time gap

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Two (10%) cases had an excellent result, eight (40%) cases had good results, seven (35%) cases had fair results, and three (15%) cases had poor results. Poor cases may be due to the long-time gap between trauma and operation, poor rotator cuff muscles, old age, or due to poor rehabilitation protocol postoperatively. Excellent and good cases may be due to a good range of motion pretrauma, small time gap between trauma and operation, good repair of rotator cuff tendons, and good rehabilitation protocol postoperatively. P value of 0.209 was not significant [Table 2].
Table 2: Relationship between the results of constant score and operative data

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Patient satisfaction

Seventeen (85%) cases were satisfied with the results and three (15%) cases were not satisfied with the procedure.


  Discussion Top


In the current study, 17 cases had improvement of the quality of life and had returned to their ordinary life, whereas three cases had no improvement. Reuther et al.[6] studied the results of shoulder hemiarthroplasty on 1107 patients with four different pathologies from the Norwegian Arthroplasty Register. The pathology of arthroplasty was rheumatoid arthritis (RA), osteoarthritis (OA), acute fractures (AF), and fracture sequelae (FS). It was found that the quality of life was improved in patients with RA, OA, and to a lesser degree in AF and FS.

Mighell et al.[7] studied the results of shoulder hemiarthroplasty in proximal humeral fractures in the term of a range of motion and quality of life after arthroplasty. It was found that there is an improvement in the quality of life after shoulder arthroplasty compared with the baseline level at trauma.

Constant score: two cases were excellent, eight cases were good, seven cases were fair, and three cases were of poor results. Boileau et al.[8] have studied the results of shoulder hemiarthroplasty in proximal humeral fractures in 71 patients. They found that 16% (11 cases) were excellent, 26% (19 cases) were good, 25% (18 cases) were fair, and 33% (23 cases) of cases were poor. Robinson et al.[9] have studied the results of shoulder hemiarthroplasty in humeral head fractures in 30 patients. They found that 20% (six cases) were excellent, 30% (nine cases) were good, 40% (12 cases) were fair, and 10% (three cases) were poor.

Postoperative complications

One case had a superficial infection which was treated by dressing and intravenous antibiotics. Two cases had postoperative dislocation of the head of the prosthesis; one case had anterior dislocation due to rupture of the subscapularis repair; and the second case had inferior dislocation due to rupture of the supraspinatus repair. Three cases were with postoperative rupture of rotator cuff repair. Sirveaux et al.[10] have studied the results of shoulder hemiarthroplasty in proximal humeral fractures in 71 patients. They found that complication occurred in 13 cases (early loss of grater tuberosity fixation in one case, greater tuberosity nonunion in four cases, greater tuberosity osteolysis in four cases, anterior dislocation in one case, transitory neurologic lesion of the radial nerve in one case, and late infection in two cases).

Patient satisfaction

Seventeen cases were satisfied, whereas three cases were not satisfied. Castricini et al.[11] studied the results of shoulder hemiarthroplasty for proximal humeral fractures on 70 patients. It was found that 59 patients were satisfied and 11 patients were not satisfied.

Range of motion: in this study, the lowest range of flexion was 20°, whereas the highest range of flexion was 105° with mean ± SD of 76.50 ± 23.46. The highest range of abduction was 95° whereas the lowest range of motion was 10° with mean ± SD of 52.25 ± 27.41. The highest range of adduction was 40° whereas the lowest range of motion was 10° with mean ± SD of 32.50 ± 13.52. The lowest range of motion was 10° with mean ± SD of 32.50 ± 13.52. The highest range of extension was 45° whereas the highest range of extension was 10° with mean ± SD of 32.00 ± 9.92. In Boss et al.[12] the highest range of flexion was 120° and the lowest range of flexion was less than 90° with the mean active flexion being 103°. The lowest range of abduction was 0° whereas the highest range was 40° with mean abduction being 19°. The lowest range of adduction was 10° and the highest range of motion was 40° with mean adduction being 32.5°. Christoforakis et al.[13] have found that the lowest range of motion was 10° and the highest range of motion was 180° with the mean active flexion being 105.7°. The lowest range of abduction was 15° and the highest range of motion was 170° with a mean of 92.4°.


  Conclusion Top


Shoulder hemiarthroplasty is a method of treatment of comminuted proximal humeral fractures in which complication of fracture fixation is avoided with a restoration of the anatomy of shoulder joint particularly in osteoporotic bone.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br 1991; 73:295–298.  Back to cited text no. 1
    
2.
Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am 2009; 91:1689–1697.  Back to cited text no. 2
    
3.
Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg 1998; 7:586–590.  Back to cited text no. 3
    
4.
Emery R, Bankes M. Shoulder replacement: historical perspectives. In: Walch G, Boileau P, editors. Shoulder arthroplasty. Berlin: Springer-Verlag; 1999. 3–9.  Back to cited text no. 4
    
5.
Bankes M, Emery RJH. Pioneers of shoulder replacement: Themistocles Gluck and Jules Emile Péan. J Shoulder Elbow Surg 1995; 4:259–262.  Back to cited text no. 5
    
6.
Reuther F, Mühlhäusler B, Wahl D, Nijs S. Functional outcome of shoulder hemiarthroplasty for fractures: a multicentre analysis. Injury 2010; 41:606–612.  Back to cited text no. 6
    
7.
Mighell MA, Kolm GP, Collinge CA, Frankle MA. Outcomes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elbow Surg 2003; 12:569–577.  Back to cited text no. 7
    
8.
Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 2001; 10:299–308.  Back to cited text no. 8
    
9.
Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for the treatment of proximal humeral fractures. J Bone Joint Surg Am 2003; 85-A:1215–1223.  Back to cited text no. 9
    
10.
Sirveaux F, Roche O, Mole D. Shoulder arthroplasty for acute proximal humerus fracture. Orthop Traumatol Surg Res 2010; 96:683–694.  Back to cited text no. 10
    
11.
Castricini R, De Benedetto M, Pirani P, Panfoli N, Pace N. Shoulder hemiarthroplasty for fractures of the proximal humerus. Musculoskelet Surg 2011; 95(Suppl 1):S49–S54.  Back to cited text no. 11
    
12.
Boss AP, Hintermann B. Primary endoprosthesis in comminuted humeral head fractures in patients over 60 years of age. Int Orthop 1999; 23:172–174.  Back to cited text no. 12
    
13.
Christoforakis JJ, Kontakis GM, Katonis PG, Stergiopoulos K, Hadjipavlou AG. Shoulder hemiarthroplasty in the management of humeral head fractures. Acta Orthop Belg 2004; 70:214–218.  Back to cited text no. 13
    



 
 
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