Extract
Results after humeral head replacement for the treatment of acute proximal
humeral fractures have been mixed. The variability in the reported outcomes
reflects the technical factors related to the reconstruction, the timing of
the surgery, the nature of the patient population, and the different methods
of assessing the results. Hemiarthroplasty for the treatment of proximal
humeral fractures provides good-to-excellent pain relief in 73% to 97% of
patients1-5.
Patients are generally satisfied with the procedure, as reflected by the 70%
to 92% satisfaction rates in most
series1,4,6-10.
Functional outcomes, however, have been variable. One of the more commonly
utilized outcome instruments is the Constant score, which measures four
clinical parameters, including pain, range of motion, power, and activities of
daily living, on a 100-point scale. Using this system, some authors have
reported average scores as low as 38 points whereas others have reported
average scores as high as 68
points3-5,10-12.
Within each series, however, there has been a broad range of results, with
excellent outcomes in some patients and poor results in
others4,5,9,11,13,14.
Results after humeral head replacement for the treatment of acute proximal
humeral fractures have been mixed. The variability in the reported outcomes
reflects the technical factors related to the reconstruction, the timing of
the surgery, the nature of the patient population, and the different methods
of assessing the results. Hemiarthroplasty for the treatment of proximal
humeral fractures provides good-to-excellent pain relief in 73% to 97% of
patients1-5.
Patients are generally satisfied with the procedure, as reflected by the 70%
to 92% satisfaction rates in most
series1,4,6-10.
Functional outcomes, however, have been variable. One of the more commonly
utilized outcome instruments is the Constant score, which measures four
clinical parameters, including pain, range of motion, power, and activities of
daily living, on a 100-point scale. Using this system, some authors have
reported average scores as low as 38 points whereas others have reported
average scores as high as 68
points3-5,10-12.
Within each series, however, there has been a broad range of results, with
excellent outcomes in some patients and poor results in
others4,5,9,11,13,14.
Look for these and other related articles in Instructional Course
Lectures, Volume 54, which will be published by the American Academy of
Orthopaedic Surgeons in February 2005:"Indications for Prosthetic Replacement in Proximal Humerus
Fractures," by Wesley P. Phipatanakul, MD, and Tom R. Norris, MD"Outcome After Treatment of Proximal Humerus Fractures with
Humeral Head Replacement," by Young W. Kwon, MD, PhD, and Joseph D.
Zuckerman, MD
Look for these and other related articles in Instructional Course
Lectures, Volume 54, which will be published by the American Academy of
Orthopaedic Surgeons in February 2005:
"Indications for Prosthetic Replacement in Proximal Humerus
Fractures," by Wesley P. Phipatanakul, MD, and Tom R. Norris, MD"Outcome After Treatment of Proximal Humerus Fractures with
Humeral Head Replacement," by Young W. Kwon, MD, PhD, and Joseph D.
Zuckerman, MD
"Indications for Prosthetic Replacement in Proximal Humerus
Fractures," by Wesley P. Phipatanakul, MD, and Tom R. Norris, MD
"Outcome After Treatment of Proximal Humerus Fractures with
Humeral Head Replacement," by Young W. Kwon, MD, PhD, and Joseph D.
Zuckerman, MD
Perioperative complications are the most important factors affecting
outcome. The reported prevalence of complications after humeral head
replacement for treatment of acute proximal humeral fractures has varied
substantially from one series to another. This variability is due, in part, to
the differences in the definition of what constitutes a complication. For
example, one series may include superficial infection as a complication
whereas in another series it may be considered only as a minor inconvenience.
The duration of clinical follow-up has also varied, further confounding the
reported rates of complications. In general, longer follow-up is associated
with an increased prevalence of complications.
Complications after humeral head replacement for the treatment of proximal
humeral fractures include infection, neurological injury, intraoperative
fracture, instability, tuberosity malunion and nonunion, rotator cuff tear,
component malpositioning, heterotopic ossification, glenoid erosion, and
stiffness. These reported complications are summarized in
Table
I1-27;
no attempt was made to combine the raw data from the retrospective series
since many complications, such as superficial infection or stiffness, are
likely to be underappreciated and underreported.
Prevention of infection after a humeral head replacement requires
meticulous surgical technique, particularly because of the potential
contamination from the axilla. Perioperative antibiotics should be utilized
routinely. Careful handling of the soft tissues is essential, particularly for
elderly patients, whose tissues are more sensitive to traumatic insults.
Recognized risk factors for infection include previous shoulder surgery,
increased surgical time, and patient comorbidities. Compromised immune
function such as that due to immuno-suppressive therapy, rheumatoid arthritis,
diabetes mellitus, and malignant lesions may also predispose patients to a
postoperative infection. Other risk factors include infection at another site,
chronic renal failure being treated with dialysis, radiation therapy, poor
nutrition, and
obesity28-31.
Infections include acute postoperative infections occurring within thirty
days after the surgery, subacute infections occurring within six months after
the surgery, and late infections occurring six months or more after the
surgery. Both acute and subacute infections usually originate from the initial
surgery. Late infections represent hematogenous seeding of the surgical site.
Subacute and late infections often present as early prosthetic loosening
(Fig. 1) and usually are not
associated with wound drainage or breakdown.
Most authors have not commented specifically on superficial infections, but
in one study the prevalence was
5.5%5. The majority
of these infections can be treated successfully with antibiotics alone. Deep
infection during the acute postoperative period is relatively uncommon, with
no more than one acute deep infection reported in several studies that
included from sixteen to seventy-two
patients2,12,15,19.
In the largest series published to date, only two deep infections were found
in 138 patients5.
One of those patients was treated successfully with surgical
débridement alone, whereas the other patient required revision of the
prosthesis.
Management of infections following shoulder arthroplasty has been largely
extrapolated from the hip and knee arthroplasty
literature28,29,32-36.
As such, the treatment is determined, in part, by the time of presentation. An
acute deep postoperative infection should be treated with urgent irrigation
and débridement. Every effort should be made to maintain the security
of the tuberosity fixation. After surgical débridement, the patient is
treated with intravenous antibiotics. The choice of antibiotic should be
determined from the results of the intraoperative culture. We encourage early
consultation with an infectious disease specialist. If the initial
débridement is not successful, the implant and the cement mantle should
be removed and an antibiotic-impregnated cement spacer should be
inserted33,36.
During the procedure, the tuberosities should be secured to the shaft in
anticipation of implantation of a new prosthesis at a later date.
Delayed infections should be treated with surgical débridement,
removal of the implant, and insertion of an antibiotic-impregnated cement
spacer (Fig. 2). Treatment of
late hematogenous infections is variable. For example, a patient in whom an
"acute" shoulder infection develops following a urinary tract or
periodontal infection can be treated with surgical débridement alone if
the radiographs and the intraoperative examination suggest that the
bone-cement interface is not involved. If the initial débridement is
not successful, however, a more extensive débridement and removal of
the prosthesis are necessary.
Treatment of an infection at the site of a prosthesis is more likely to be
successful when the involved organism has a high sensitivity to standard
intravenous antibiotics. Pseudomonal infections are particularly difficult to
treat because of the organisms' slow rate of replication and resistance to
many antibiotics37.
Although the subject is somewhat controversial, other gram-negative organisms
have also been considered to be difficult to
eradicate37.
In addition to infections, other soft-tissue complications may also occur,
at a very low rate. To our knowledge, only one superficial wound dehiscence
has been reported in the literature; it was successfully managed with local
wound care3. In
addition, only a few symptomatic hematomas have been
reported5,18,19.
Typically, awareness and prompt recognition provide the basis for successful
management of these complications.
Neurological injury from proximal humeral fractures is an underappreciated
complication. The prevalence of neuro-logical injury reported in the
literature has been based on the initial clinical assessment. When
electrodiagnostic studies have been done, however, nerve injury has been
identified in up to 67% of patients with a proximal humeral
fracture38,39.
Preoperative clinical recognition of a neurological injury has been reported
in up to 15% of patients requiring
hemiarthroplasty5.
Nerve injuries that occur during the surgical procedure are much less common.
When they do occur, most are transient and rarely result in a permanent
deficit. The distinction between a nerve injury that occurs after the initial
trauma from one that occurs during the surgery is important for patient
management as well as for medicolegal reasons.
The axillary nerve is the most commonly injured nerve, with the rate of
injury being as high as 12.5% in one
series5,26,27.
The second most common nerve injury involves the brachial plexus. These
injuries have been reported in up to 6.1% of
cases5,6,19.
Isolated radial or median nerve palsies have been reported, but their
prevalence is
<1%5. In an
earlier study, Neer and
McIlveen20 reported
higher rates of median and radial nerve injuries as well as one
musculocutaneous and two ulnar nerve injuries. However, those injuries were
believed to have occurred during the initial attempts at reduction prior to
the
hemiarthroplasty20.
We are not aware of any other reports of isolated musculocutaneous or
suprascapular nerve injuries in the literature. The lack of such reported
injuries seems to be due to the difficulty in recognizing the deficit in an
acutely injured patient. When electrodiagnostic studies have been performed in
patients with a proximal humeral fracture, the prevalence of abnormalities in
the musculocutaneous and suprascapular nerves have been reported to be 29% and
48%,
respectively39.
Operative management of proximal humeral fractures is associated with a low
risk of nerve injury. Transient axillary nerve palsy related to the surgical
procedure occurs in <5% of
cases1,4,5,14,26.
The injury typically occurs at the inferior aspect of the glenohumeral joint
as the nerve passes in an anterior-to-posterior direction. This area must be
explored carefully with clear visualization. Often, the injury is caused by a
misplaced retractor or overly aggressive retraction. Continuous awareness of
the location of the nerve, usually through palpation or direct visualization,
is crucial to avoiding injury. The musculocutaneous nerve may also be injured
by inappropriate retraction, particularly if the retraction is applied more
distally on the undersurface of the conjoined tendon. Most injuries of the
suprascapular nerve occur during surgery for a chronic fracture that requires
extensive mobilization of the tuberosities and/or rotator cuff. Direct injury
to the suprascapular nerve can occur when dissection and mobilization are
carried out more than 1 cm medial to the superior and posterior glenoid
margin. Isolated radial nerve injury during humeral head replacement is rare
and has been reported only
once14.
Although most injuries are neurapraxias, permanent nerve injuries may occur
after the initial trauma or after the surgery. If there are concerns that a
direct nerve injury (i.e., a laceration) has occurred, electrodiagnostic
studies should be performed. If the study indicates a disruption of the nerve,
early exploration and repair should be considered. Unfortunately, there are
insufficient data regarding the prevalence of permanent nerve injury. In the
largest reported series to date, twenty-one (15%) of 138 patients had
preoperative neurological symptoms, with nine (6.5%) having persistent
symptoms beyond six
weeks5.
The prevalence of intraoperative fractures has been reported to be 1% to 3%
during total shoulder
arthroplasty40 and
even lower during hemiarthroplasty for proximal humeral fractures. We are
aware of only one report of an intraoperative fracture during the treatment of
an acute proximal humeral
fracture16.
However, when the surgery has been performed to treat the late complications
of these fractures, the prevalence of intraoperative fracture has been as high
as 5.5%24. Since
some intraoperative fractures may be unrecognized and stabilized by the cement
mantle, it is possible that they are underreported in the acute setting.
Treatment of an intraoperative fracture depends on the location and the
extent of propagation. Fractures in the proximal portion of the shaft that do
not extend beyond the distal tip of the humeral stem can usually be treated
with cerclage wire fixation. If the fracture extends distal to the standard
humeral component, a long-stem component should be used. The prosthesis should
extend at least two cortical diameters distal to the fracture, and a cerclage
wire should be used for supplementary fixation. If a long-stem component is
not available, a plate or a biological strut graft across the fracture site
can be applied. During the insertion of the prosthesis, care must be taken to
prevent extravasation of the cement through the fracture site, as the heat
from the curing process may damage the nearby neurovascular
structures41.
In most instances, intraoperative fractures can be prevented by utilizing
meticulous surgical technique. Forced manipulation of the shaft should be
avoided. Proper positioning of the patient on the operating table to allow
full extension of the humerus provides adequate exposure for the insertion of
the humeral component. In addition, drill holes in the humeral shaft for the
fixation of the tuberosities should be placed distally in order to minimize
the possibility of fracture propagation. In severely osteopenic bone, a cement
restrictor may not be appropriate because excessive pressurization within the
canal may occur.
The definition of instability of the glenohumeral joint after humeral head
replacement has been inconsistent in the literature. Thus, the reported rates
of this complication have been variable. Some authors have defined superior
subluxation as instability, whereas others have considered it to be a
complication related to the rotator cuff. Inferior instability is also not
well defined since inferior subluxation is a common post-operative finding
thought to be related to deltoid atony. Inferior subluxation usually resolves
spontaneously. Persistent inferior subluxation may represent a nerve injury or
malpositioning of the prosthesis and usually does not cause the sensation of
instability.
Anterior and posterior instability usually presents with the typical
symptoms of subluxation or dislocation. Even in the absence of a documented
dislocation, excessive translation in the anterior-posterior direction has
been found in up to 7.1% of
patients6,10,24.
Dislocation after humeral head replacement is less common. Hawkins and
Switlyk1 reported
one dislocation in their series of twenty patients, and Robinson et
al.5 reported three
dislocations (2.2%) in their series of 138 patients.
Factors that increase the risk of joint instability include failure to
restore the physiologic version and height of the humeral head component,
compromise of the rotator cuff, and problems related to the tuberosities.
Often, instability develops as a result of resorption or migration of a
tuberosity. Detachment of the lesser tuberosity compromises the anterior
shoulder restraint and may lead to anterior instability, especially with
external rotation. Detachment of the greater tuberosity can result in superior
migration of the humeral head as well as anterior instability. Although
posterior instability can occur, it is less common.
Treatment of glenohumeral joint instability after humeral head replacement
is based on the severity of the symptoms. For patients with no gross
structural defects or component malposition, rehabilitation and activity
modification may be sufficient. If the symptoms persist or if there are
structural abnormalities, operative intervention must be considered. The goal
of these procedures is to restore the normal anatomy and the constraints of
shoulder stability. In rare instances, the procedure may require the use of
allografts or autografts to augment the surrounding
structures42.
Reconstruction of the tuberosities has been increasingly recognized as a
crucial element influencing the clinical
outcome10,12,26.
Many complications are associated with improper function of the tuberosities
and the rotator cuff. They include postoperative migration, nonunion,
malunion, and resorption of the tuberosities.
Migration and Nonunion
Postoperative migration of the tuberosities
(Fig. 3) is a common
complication that substantially increases the likelihood of a poor functional
outcome26. The
prevalence of tuberosity migration has been reported to be between 2% and
23%4-6,9,10,18,24,26.
The method of tuberosity attachment and the ability to obtain secure fixation
are the key elements influencing tuberosity stability and subsequent union.
Overall bone quality has also been suggested to influence the likelihood of
tuberosity
migration26. The
clinical importance of postoperative migration appears to be determined by the
degree of migration. Minimal migration and displacement frequently result in
weakness and a decreased range of motion whereas, with more displacement,
instability and pain may also be present. In this clinical setting, operative
management should be considered, with the goals of mobilizing the tuberosities
and obtaining a secure reattachment.
Given the high rate of tuberosity migration, it is not surprising that the
prevalence of tuberosity nonunion has been as high as
17%6,10,24,26.
Although the clinical relevance may vary among individuals, this complication
is usually associated with an inferior outcome. For patients with substantial
symptoms, operative intervention to reattach the tuberosities should be
considered. In some cases, this may be difficult since the factors that
resulted in the original nonunion may still be present.
During the operation, all attempts should be made to provide maximal
stability to the tuberosity fixation. We previously described the concept of
defining fixation in the longitudinal and transverse
directions43. After
contact between the tuberosities and the shaft has been confirmed, sufficient
longitudinal fixation should be placed to allow early rehabilitation. For
transverse fixation, the tuberosities should be in contact with each other and
should be stabilized with cerclage fixation that encompasses both of the
tuberosities and the humeral component. Multiple sutures should be used to
maximize the stability. It is recommended that, when possible, cancellous bone
graft from the removed humeral head be used to enhance the healing
potential.
Malunion
Malunion of the tuberosities may occur as a result of improper
intraoperative positioning or after tuberosity migration. Proper positioning
of the tuberosities has been critically evaluated only
recently4,12,26.
In one recent series, the prevalence of tuberosity malunion was reported to be
as high as 39%26.
When the initial postoperative radiographs were critically appraised, initial
malpositioning of the tuberosity was found in 27% of those
patients26. In the
coronal plane, the greater tuberosity was positioned either too inferiorly
(>10 mm inferior to the top of the humeral head) or too superiorly (<5
mm inferior to the top of the humeral head) in 18% of the patients. In the
sagittal plane, horizontal malpositioning was found in 23% of the patients.
Mighell et al.12,
who used slightly different criteria to define malreduction in their series,
found that the tuberosities were malpositioned in 21% of their seventy-two
patients.
When malunited, the lesser tuberosity often heals medial to its original
position. This medialization can cause limitations in internal rotation
strength. However, malunion of the lesser tuberosity does not usually cause
substantial clinical symptoms. In contrast, malunion of the greater tuberosity
is associated with a substantially inferior
outcome10,12,26.
If the greater tuberosity is too superior, it will impinge against the
acromion as well as limit forward elevation and abduction. If the tuberosity
is too posterior, there may be substantial loss of external rotation.
Treatment of tuberosity malunion should be guided by the clinical symptoms
and the extent of functional impairment. A revision operation typically
consists of osteotomy, mobilization, and reattachment in the anatomic
position44. The
scar tissue generated from the previous injury and surgery makes surgical
exposure and identification of the tuberosity fragment difficult. In addition,
the osteotomized fragment must be adequately mobilized in order to obtain a
tension-free reconstruction, although this may not be possible in patients
with severe rotator cuff muscle contractures. Finally, the presence of the
humeral head prosthesis can interfere with the placement of transosseous
fixation. If a modular humeral component is present, it may be possible to
exchange the humeral head for a smaller one in order to reduce tension on the
tuberosities.
For certain patients in whom the greater tuberosity is too superior,
isolated subacromial decompression can be
considered45,46.
However, this procedure does not correct the underlying deformity and should
be considered only when the superior displacement is limited. In addition,
subacromial decompression may lead to rupture of the coracoacromial ligament.
Without a competent coracoacromial arch, anterosuperior instability may ensue
and cause additional clinical symptoms.
Tuberosity Resorption and Rotator Cuff Tears
Compromise of the rotator cuff may be identified at the time of the initial
operation or it may be inferred at follow-up from radiographs showing
resorption of the greater tuberosity and superior migration of the humeral
head1,3,4,6-8,12,14,24,26.
Typically, the patient exhibits a lack of recovery or a gradual loss of active
motion. It is often difficult to determine whether the compromise of the
rotator cuff is a result of progressive tissue degeneration or is secondary to
the loss of tuberosity fixation. Uncommonly, a patient who had regained good
active motion and function may sustain an injury that results in a rotator
cuff tear. Even in the absence of trauma, an acute rotator cuff injury must be
considered if a patient has a sudden loss of active motion.
The diagnosis of acute rotator cuff tears is based on clinical examination
with confirmation by radiographic studies. Both magnetic resonance
imaging47 and
ultrasound48 have
been utilized for diagnosis. However, interpretation of these studies often
requires considerable expertise and experience. Another useful radiographic
study is arthrography, as it can clearly demonstrate a full-thickness rotator
cuff tear. If an acute full-thickness tear is confirmed, operative repair
should be considered. However, it is important to emphasize that this should
be considered only for a patient with an acute tear. Patients with a chronic
tear with or without tuberosity resorption are usually not candidates for
surgery. To our knowledge, there is no information regarding this specific
issue in the literature. Thus, management of this complication should be
individualized and based on established principles.
Operative management provides only limited benefits for patients with a
gradual loss of rotator cuff function and possible tuberosity resorption.
Nonoperative treatment, including pain management, a limited-goal therapy
program, and supportive care, is the preferred approach. There may be a role
for the reverse design shoulder prosthesis for patients with this difficult
complication49.
However, the clinical efficacy of this revision surgery has not yet been
documented.
Malpositioning
Insertion of the humeral component in anatomically appropriate amounts of
version and height is critical to the outcome. In most instances, anatomical
landmarks can be utilized to place the humeral component in 20° to 40°
of retroversion. The humeral head should interact concentrically with the
glenoid surface such that the superior tip of the metallic head is roughly
equivalent to the top of the glenoid. Ideally, the top of the humeral head
should also be 4 to 6 mm superior to the top of the greater tuberosity.
Component positioning had not been critically reviewed in the literature until
recently, when Boileau et
al.26, using
postoperative computed tomography, found that nine (39%) of the twenty-three
patients in their series had the humeral component placed in >40° of
retroversion. Comparison with radiographs of the uninjured limbs as controls
for humeral length revealed that 26% of the humeral stems had been placed
>10 mm too superiorly and 36% of the stems had been placed >10 mm too
inferiorly26.
Identifying the proper version and height of the humeral component may be
difficult in some instances because of the limited exposure and the lack of
anatomical landmarks. In addition, component version and height may also be
inadvertently altered when the prosthesis is finally inserted into the cement
mantle. Although some authors have described techniques that do not utilize
cement, we believe that cement is mandatory in order to maintain proper
positioning and provide rotational stability. If substantial component
malpositioning is identified, either intraoperatively or postoperatively, and
is thought to result in instability, the component should be revised.
Loosening
The prevalence of radiolucent lines around the humeral prosthesis is
variable, with reported rates of between 0% and
32%1-3,5,6,8-12,14,15,24,26.
Despite the presence of radiolucent lines, symptomatic aseptic loosening
requiring revision is an uncommon problem, occurring in <2% of
patients12.
Prostheses inserted without the aid of a cement mantle are associated with a
higher rate of aseptic
loosening1.
Loosening of the humeral component is usually associated with progressive
radiolucency at the bone-cement interface
(Fig. 4). The diagnosis of
loosening is established by using criteria similar to those for femoral
component loosening after total hip
arthroplasty50.
Definitive loosening is thought to have occurred if the prosthesis has changed
position, the cement mantle has fragmented or fractured, there is a
progressive radiolucent line at the cement-prosthesis interface (debonding),
or the prosthesis is broken or bent.
If the component is loose, the patient must be evaluated for the presence
of an underlying deep infection. This evaluation may include joint aspiration
as well as laboratory tests such as a white blood-cell count and determination
of the erythrocyte sedimentation rate and C-reactive protein level. Other
sources of shoulder pain and discomfort must also be considered. If component
loosening is the primary source of symptoms, revision surgery should be
considered. If possible, the entire cement mantle should be removed, and the
new prosthesis should be inserted with careful attention to cementing
techniques. Use of a long-stem component can be considered if there are
substantial endosteal bone defects. Although insertion of a noncemented
implant may be considered, lack of metaphyseal bone support often precludes
this option.
Heterotopic ossification following a humeral replacement is relatively
common, occurring in 25% to 56% of
cases11,12.
Mighell et al.12
reported that mild heterotopic ossification (grade I or
II51) was found in
17% of their patients and more extensive heterotopic ossification (grade III
or IV51) was found
in only 7%. Other authors have also observed heterotopic ossification in their
patients, but their reported rates have been
variable1,3,4,6,7,10,15,26.
Several patient-related factors predispose to the formation of heterotopic
bone. Ankylosing spondylosis, diffuse idiopathic skeletal hyperostosis, and a
history of heterotopic bone formation have all been associated with an
increased risk52.
Other independent risk factors include high-energy injuries and a delay in the
treatment beyond ten to fourteen
days20,21,28.
We have also found that heterotopic ossification can develop when a revision
procedure is performed following an early failure of internal fixation,
especially when the second procedure is performed two to four weeks after the
initial procedure.
Fortunately, most patients with heterotopic ossification in the shoulder
exhibit minimal
symptoms53. If,
however, the heterotopic bone is excessive, it can adversely affect the range
of motion. Surgical excision should be considered when a patient demonstrates
functional limitations. Excision should be attempted only after the
ossification process has matured and the radiographic margins are clearly
defined. For most patients, this requires a timeperiod of at least six months
after the initial
surgery52. In
addition to the standard radiographs, computed tomography is usually necessary
for accurate localization of the ossification. Bone within or bridging the
subacromial space is typically easy to locate and excise. If the bone has
formed within the rotator cuff, the excision must be combined with a repair of
any full-thickness defects in the rotator cuff tendons. Excessive bone that is
overlying the glenohumeral joint may be in close proximity to the axillary
nerve and other branches of the brachial plexus. Therefore, bone excision in
this area requires meticulous dissection.
The initial humeral head replacement as well as the excision of heterotopic
ossification requires meticulous technique to minimize soft-tissue trauma. In
addition, these procedures should be performed at the appropriate time, and
the "at risk" period should be avoided. For patients considered to
be at high risk for heterotopic bone formation, prophylaxis with indomethacin
or radiation therapy should be considered.
As the radiographic appearance of degenerative changes in the glenoid is
subject to interpretation, the reported prevalence of such changes has been
variable. In general, glenoid wear requiring revision surgery is fairly
uncommon. Mighell et
al.12 reported
that, in their series of seventy-two patients, only three had glenoid
degeneration requiring a revision operation. This low rate of glenoid wear may
be due in part to the relatively low activity level of the typical patient who
sustains a proximal humeral fracture. Factors that contribute to the
development of glenoid degeneration include preexisting loss of cartilage
prior to the surgery, unrecognized injury or additional injury at the time of
the surgery, and the activity level of the
patient12. The
duration of follow-up may also influence the prevalence of this complication,
as glenoid degeneration is more likely to develop over time.
The treatment of loss of glenoid articular cartilage is generally
determined by the severity of the symptoms. When there is evidence of glenoid
degeneration (Fig. 5), it must
first be confirmed that the symptoms are from the glenoid and not from other
sources. An intra-articular injection of lidocaine can help to confirm this
diagnosis. If the symptoms are mild or moderate, anti-inflammatory medications
and activity modification may be sufficient. If there is substantial pain and
disability, however, revision surgery with insertion of a glenoid component
should be considered. Preoperative radiographs must be scrutinized to ensure
that adequate bone stock is present to support a glenoid component.
Stiffness is difficult to define since many of the other complications
discussed above result in decreased range of motion. Patients with good
passive motion but poor active motion may have musculotendinous, neurological,
or tuberosity-related complications as discussed previously. For the purpose
of this article, stiffness will be defined as loss of both active and passive
motion that compromises function. The prevalence of clinically relevant
stiffness is relatively low: only one case requiring surgical release has been
reported in the
literature2.
The initial treatment for stiffness is aggressive rehabilitation. If
disability persists, soft-tissue release can be considered. The release can be
performed after an open exploration or through an arthroscopic approach.
Arthroscopic release minimizes soft-tissue dissection, but it can be
technically demanding. Initial steps involve intra-articular circumferential
capsular release. The subacromial space is then addressed with complete
bursectomy and release of scar tissue. Gliding of the rotator cuff tendon
within the subacromial space must be restored. In most instances, we also
recommend a release of the coracoacromial ligament as well as a limited
acromioplasty. Upon completion of the procedure, a gentle manual manipulation
of the shoulder is performed to gain additional motion. The degree of motion
obtained in the operating room is the long-term postoperative goal. A
structured and supervised rehabilitation program is essential to maintain any
improvements. Typically, the patient is admitted to the hospital for two to
three days in order to initiate this therapy program. Postoperative analgesia
can be augmented with an interscalene block on the first and second
postoperative days to allow aggressive rehabilitation with minimal pain.
Humeral head replacement is an acceptable, and often preferred, method of
treatment of complex proximal humeral fractures. Although the procedure is
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