Treatment of Proximal Humeral Fractures with a Prosthesis The PolyClinic and

Treatment of Proximal Humeral
Fractures with a Prosthesis
Carl J. Basamania, MD, FACS
The PolyClinic and
Swedish Orthopaedic Institute
Seattle, Washington
Proximal Humerus Fractures
• Common injuries: 5-7% all fractures (80,000/yr)
• Humerus is the second most frequently fractured
long bone of the upper extremity
• 45% of humerus fractures
• Female:Male - 2:1
• Increased incidence in elderly population
• Osteoporosis – related
• 80-85% minimally displaced/stable
Proximal humerus fractures
are the 3rd most common
fractures in elderly patients
As longevity increases the
number of fractures is expected
to grow substantially
The Number and Incidence (per 100,000 individuals) of hospital
treated osteoporotic fractures of the proximal humerus in patients 60
years and older in Finland from 1970 to 2002
Treatment of Proximal Humerus
• General Rules:
– “However you decide to treat a proximal humerus
fracture, the most important rule is that you have to be
able to move the patient right away…if you don’t, you’ll
have pretty
x-rays and no function.”
» Charles A. Rockwood, Jr
– Always err on trying ORIF rather than arthroplasty in
younger patients
– Good equipment will not make up for
poor surgical technique
Scarring – The Single Most
Common Complication
• Soft tissue damage
– Increases with surgery
Soft tissue swelling
• Considerations
Patient’s health/comorbidities
Musculoskeletal comorbidities
Bone quality—osteoporosis
Degree of displacement
Physiologic age
Soft tissue
Arm dominance
Expectations/functional needs
Fractures to Consider
• Young/middle age
– Nonreconstructable articular
surface (severe head split)
or extruded anatomic neck
• Elderly
– Most 4 parts
– Some severe 3 parts
– Most 3-, 4-part fracture
– Most head splits
Four-Part Valgus-Impacted
• Head angulated
and impacted
• Not a true 4-part
• ORIF + bone graft
Surgical Principles
Maintain deltoid integrity
Restore anatomy
Restore humeral length
Restore humeral version
Maintain stable fixation of:
– Tuberosities to each other
– Tuberosities to shaft
Challenges Unique to Fractures
• Selecting proper prosthesis height
• Proper humeral component version
• Achieving anatomic and secure tuberosity
Advantages of Prosthetic Replacement
• Secure fixation
• Predictable pain relief
• Revision of failed osteosynthesis is difficult
Disadvantages of Prosthetic
Larger incisions
Time/blood loss
Complications serious/difficult
Global Fx
• Available Porous and Non Porous coated
• Unique positioning jig
Global Fx Prosthesis Advantages
Thin body
Anterior fin
Medial fin hole
Reduced lateral fin
Taper/Flute stem
Surgical Approach
• Beach Chair
• Beach Chair
• Antibiotics
• Preoperative scrub
• Deltopectoral Interval
• Deltopectoral Interval
• Conjoined Tendon
• Deltopectoral Interval
• Conjoined Tendon
• Nerve Identification
• Deltopectoral Interval
• Conjoined Tendon
• Nerve Identification
Identify Biceps
Identify Fracture Lines
Measure Head
Surgical Technique
• Tuberosities tagged
• Humeral head removed
Surgical Technique
• Ream Humeral Shaft
• Establish Humeral Height
Important Anatomic Relationships
• The average neck-shaft angle is 40 to 45
degrees with a range of 30 to 55 degrees
• Vertical distance between highest point of
humeral articular surface and highest point
of the greater tuberosity (head to greater
tuberosity height) is ~8 mm with relatively
small range of interspecimen variability
Correct Head Height
• The distance from the upper margin of the
pectoralis major insertion to restore the
anatomy should be 17.55% of the total
humeral length.
• Anatomy can be restored by placing the
prosthesis 5.6 cm above the upper insertion
of the pectoralis major
– J Shoulder Elbow Surg 2008;17:947-950
Correct Head Height
Murachovsky, et al. J Shoulder Elbow Surg, 15, 6, 2006
Surgical Technique
• Ream Humeral Shaft
• Establish Humeral
• Establish Humeral
Surgical Technique
Surgical Technique
• Cement Final Components
• Tuberosity repair
Tuberosity Repair to Anterior Fin
Tuberosity Repair to Lateral Fin
The “around the world” stitch
• Mark A. Frankle, JSES, 2004
What contributes to better outcome?
• Factors contributing to a
favorable result include:
– younger age,
– male sex,
– fracture type (i.e., three-part
versus four part),
– adequate rotator cuff repair or
tuberosity reconstruction,
– use of cement
– sufficient postoperative
rehabilitation compliance
Prosthetic Replacement Outcome
• 16 studies dealing with 810
hemiarthroplasties in 808 patients
• Mean age of 67.7 years (22 to 91)
• Mean follow-up of 3.7 years
• Mean FF 105.7° (10° to 180°) and mean
abduction 92.4° (15° to 170°)
• Mean Constant score 56.63 (11 to 98)
Prosthetic Replacement Outcome
• Complications related to the fixation and
healing of the tuberosities in 86 of 771 cases
• Heterotopic ossification 8.8% and proximal
migration of the humeral head 6.8%
• Incidence of superficial and deep infection
was 1.55% and 0.64%
– Kontakis, et al. JBJS Br, 90-B: 1407 – 1413, 2008
Predictors of poor outcome
Women over 75 years old had poorer results
Humeral retroversion > 40 degrees
Prosthesis >10mm above tuberosities
Greater tuberosity >5mm above humeral
• Worst association was a prosthesis that was
too high and too retroverted with a low
greater tuberosity: the “unhappy triad”
P. Boileau, et al, JSES, 2002
Poor Results
• Malposition of
either the
tuberosities or
head height can
result in poor
– Boileau, et al,
JSES, 2002
Disappearing tuberosities
Disappearing Tuberosities
Reverse TSA for Fractures
• Average postop FF 97 degrees
• In 36 shoulders in which the tuberosities had been fixed,
secondary displacement occurred in 19 (53%), leading
to malunion in five (13.8%) and nonunion in 14 (38.8%)
Bufquin, et al, JBJS(B), 89-B, 4, 2007
• Proximal humerus fractures represent the
“last frontier” of fracture management
• Very common
• Typically complicated by osteoporosis
• Fixation technique should be strong enough
to allow early motion
• Need to control scarring
Thank you!
Wound infection
Nerve injury
Tuberosity nonunion/malunion
Cuff Dysfunction