Boileau, J Shoulder Elbow Surg 2002 - Tuberosity Malposition and Migration: Reasons for Poor Outcomes after Hemiarthroplasty for Displaced Fractures of the Proximal Humerus
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Tuberosity Malposition and Migration: Reasons for Poor Outcomes after Hemiarthroplasty for Displaced Fractures of the Proximal Humerus
Boileau, Molé, et al.·J Shoulder Elbow Surg·2002·613 citations·Retrospective cohort
Boileau and colleagues assessed outcomes after hemiarthroplasty for displaced fractures of the proximal humerus and sought the clinical and radiographic factors behind poor results.
Prospective study at 8 centers, 1991 to 1996. 73 consecutive acute 3- and 4‑part fractures were treated, and 66 patients were analyzed at a mean of 27 months.
Methods
Design
Prospective multicenter study
Treated 1991 to 1996
Data source
8 centers, each case supervised by a senior shoulder surgeon
Patients
73 consecutive acute 3- and 4‑part fractures treated
66 analyzed after 3 deaths and 4 lost to follow‑up
45 women and 21 men
Mean age 66 (range 31 to 85)
Exposure
Hemiarthroplasty with the same nonconstrained prosthesis in all patients
Tuberosity osteosynthesis
Follow-up
Mean 27 months (range 18 to 59)
Outcomes
Patient satisfaction
Constant score
Active motion
Radiographic tuberosity and prosthesis position
Key Findings
At final review the tuberosities were malpositioned in 33 of 66 patients (50%), and this was linked to unsatisfactory results, superior prosthetic migration, stiffness or weakness, and persistent pain.
Tuberosities detached and migrated in 15 patients (23%), including 5 whose tuberosities had been fixed in an anatomic position.
A proud prosthesis, lengthening the humerus more than 10 mm, was associated with poor function and with the head riding up under the acromion, while shortening was tolerated until it passed 15 mm.
All 9 shoulders with retroversion above 40° had posterior migration of the greater tuberosity and a poor result, with active elevation averaging 78° and external rotation 6°.
Women older than 75 had poorer results (p = 0.05), which the authors attributed to likely osteopenic bone.
Function was modest overall, with a mean absolute Constant score of 56 of 100 (range 20 to 95), active elevation averaging 101° and external rotation averaging 17.5°.
Board pearl
The "unhappy triad" is a prosthesis set too high and too retroverted with the greater tuberosity fixed too low, and all 5 shoulders with it had tuberosity migration, prosthetic migration under the acromion, and a poor, painful, stiff result.
Authors' conclusion
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.
Boileau and colleagues assessed outcomes after hemiarthroplasty for displaced fractures of the proximal humerus and sought the clinical and radiographic factors behind poor results.
Prospective study at 8 centers, 1991 to 1996. 73 consecutive acute 3- and 4‑part fractures were treated, and 66 patients were analyzed at a mean of 27 months.
Methods
Design
Prospective multicenter study
Treated 1991 to 1996
Data source
8 centers, each case supervised by a senior shoulder surgeon
Patients
73 consecutive acute 3- and 4‑part fractures treated
66 analyzed after 3 deaths and 4 lost to follow‑up
45 women and 21 men
Mean age 66 (range 31 to 85)
Exposure
Hemiarthroplasty with the same nonconstrained prosthesis in all patients
Tuberosity osteosynthesis
Follow-up
Mean 27 months (range 18 to 59)
Outcomes
Patient satisfaction
Constant score
Active motion
Radiographic tuberosity and prosthesis position
Key Findings
At final review the tuberosities were malpositioned in 33 of 66 patients (50%), and this was linked to unsatisfactory results, superior prosthetic migration, stiffness or weakness, and persistent pain.
Tuberosities detached and migrated in 15 patients (23%), including 5 whose tuberosities had been fixed in an anatomic position.
A proud prosthesis, lengthening the humerus more than 10 mm, was associated with poor function and with the head riding up under the acromion, while shortening was tolerated until it passed 15 mm.
All 9 shoulders with retroversion above 40° had posterior migration of the greater tuberosity and a poor result, with active elevation averaging 78° and external rotation 6°.
Women older than 75 had poorer results (p = 0.05), which the authors attributed to likely osteopenic bone.
Function was modest overall, with a mean absolute Constant score of 56 of 100 (range 20 to 95), active elevation averaging 101° and external rotation averaging 17.5°.
Board pearl
The "unhappy triad" is a prosthesis set too high and too retroverted with the greater tuberosity fixed too low, and all 5 shoulders with it had tuberosity migration, prosthetic migration under the acromion, and a poor, painful, stiff result.
Authors' conclusion
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.