Elsevier

Journal of Shoulder and Elbow Surgery

Volume 11, Issue 5, September–October 2002, Pages 401-412
Journal of Shoulder and Elbow Surgery

Original article
Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus*

https://doi.org/10.1067/mse.2002.124527Get rights and content

Abstract

The purpose of this study was to evaluate the results of hemiarthroplasty for displaced proximal humeral fractures and to assess clinical and radiologic parameters that could explain unsatisfactory results. Sixty-six consecutive patients (45 women and 21 men) with a mean age of 66 years (range, 31-85 years) were followed up postoperatively for a mean of 27 months (range, 18-59 months), both clinically and radiologically. Subjectively, 29 patients were very satisfied, 9 were satisfied, and 28 were unsatisfied. Postoperative active elevation averaged 101° ± 33°, external rotation averaged 18° ± 15°, and internal rotation averaged the L3 level (±3 vertebrae). The absolute Constant score averaged 56 of 100 points (range, 20-95 points). Initial tuberosity malposition was present in 18 patients (27%). Tuberosity detachment and migration were noted in 15 patients (23%). Tuberosity migration could be observed after initial tuberosity malpositioning, as well as after initial correct positioning. Final tuberosity malposition occurred in 33 patients (50%) and correlated with an unsatisfactory result, superior migration of the prosthesis, stiffness or weakness, and persistent pain. Factors associated with failure of tuberosity osteosynthesis were poor initial position of the prosthesis (specifically, excessive height and/or retroversion), poor position of the greater tuberosity, and women over age 75 years (likely with osteopenic bone). Techniques to improve tuberosity osteosynthesis, including modifications to current prosthetic design and instrumentation to allow for a more anatomic reconstruction, should lead to more predictable and satisfactory results. (J Shoulder Elbow Surg 2002;11:401-12)

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.

. Absolute Constant score (mean, 56 points).

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).

. Active anterior

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]).

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