Original articleTuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus*
Introduction
Although displaced proximal humeral fractures involving the tuberosities and the articular surface are often treated by hemiarthroplasty, the results remain unpredictable. In 1970 Neer30 reported the results of prosthetic replacement in displaced 3- and 4-part fractures and fracture-dislocations of the proximal humerus: excellent or satisfactory results were obtained in 90% of the patients.29, 30, 31, 32 However, a critical review of the literature reveals that no other studies have been able to reproduce the results obtained by Neer.*
These other authors have reported less satisfactory or even disappointing results with stiff and painful shoulders, demonstrating that shoulder replacement itself is not a guarantee of successful outcome in these complex injuries.
Unpredictable results may be related to the relative infrequency of these fractures, and a lack of experience of the treating surgeon potentially may contribute to inexact technique.1, 2, 4, 6, 10, 27, 43 In fact, recent authors have questioned the original recommendations of Neer and Stableforththat comminuted fractures of the proximal humerus should be treated with prosthetic replacement.30, 39
The purpose of this prospective multicenter study was to evaluate the results after hemiarthroplasty for displaced proximal humeral fractures and to assess clinical and radiologic parameters that could both explain unsatisfactory results and guide future treatment considerations.
Section snippets
Materials and methods
Between 1991 and 1996, 73 consecutive acute 3- and 4-part displaced proximal humeral fractures underwent operative treatment with the same nonconstrained shoulder prosthesis. All patients were treated under the direct supervision of a senior shoulder surgeon at 8 different centers. All fractures were classified by the Neer and AO systems.22, 29 The classification was established by the preoperative radiographs, a preoperative computed tomography (CT) scan (performed in 38 four-part fractures),
Clinical results
At final review, the absolute Constant score averaged 56 out of 100 points (range, 20-95 points). Figure 1 summarizes the values of the absolute Constant score.The Constant score, normalized for age and sex, averaged 74% (range, 31%-116%).
The results were rated as excellent in 15 patients (22.5%), good in 16 (24.5%), fair in 22 (33%), and poor in 13 (20%). Postoperative active elevation averaged 101° (range, 30°-175°) (Table II).
Discussion
This study demonstrates that the functional results after hemiarthroplasty for 3- and 4-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Initial tuberosity malposition was present in 18 patients (27%). TDM was observed in 15 patients (23%). Final tuberosity malposition occurred in 33 patients
Acknowledgements
We thank M. Basso (Giens), J. F. Kempf (Strasbourg), L. Favard (Tours), J. C. Lehuec (Bordeaux), and H. Mestdagh (Lille) for providing some of the cases in this study.
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Reprint requests: Pascal Boileau, MD, Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Hôpital de L'Archet–University of Nice, 151, Route de St Antoine de Ginestière, 06202 Nice, France. (E-mail: [email protected]).