J Korean Orthop Assoc.  2019 Apr;54(2):110-119. 10.4055/jkoa.2019.54.2.110.

Shoulder Replacement Arthroplasty after Failed Proximal Humerus Fracture

• Park JY
• Seo BH
• Lee SJ

• KMID: 2444775
• DOI: http://doi.org/10.4055/jkoa.2019.54.2.110

Abstract

Proximal humerus fracture can be defined as a fracture that occurs in the surgical neck or proximal part of the humerus. Despite the appropriate treatment, however, various complications and sequelae can occur, and the treatment is quite difficult often requiring surgical treatment, such as a shoulder replacement. The classification of sequelae after a proximal humerus fracture is most commonly used by Boileau and can be divided into two categories and four types. Category I is an intracapsular impacted fracture that is not accompanied by important distortions between the tuberosities and humeral head. An anatomic prosthesis can be used without greater tuberosity osteotomy. In category I, there are type 1 with cephalic collapse or necrosis with minimal tuberosity malunion and type 2 related to locked dislocation or fracture-dislocation. Category II is an extracapsular dis-impacted fracture with gross distortion between the tuberosities and the humeral head. To perform an anatomic prosthesis, a tuberosity osteotomy should be performed. In category II, there are type 3 with nonunion of the surgical neck and type 4 with severe tuberosity malunion. In type 1, non-constrained arthroplasty (NCA) without a tuberosity osteotomy should be considered as a treatment. On the other hand, reverse shoulder arthroplasty (RSA) should be considered if types 1C or 1D accompanied by valgus or varus deformity or severe fatty degeneration of the rotator cuff. In general, the results are satisfactory when NCA is performed in type 2 sequelae. On the other hand, RSA can be considered as an option when there is no bony defect of the glenoid and a defect of the rotator cuff is accompanied. In type 3, it would be effective to perform internal fixation with a bone wedge graft rather than shoulder replacement arthroplasty. Recent reports on the results of RSA are also increasing. On the other hand, recent reports suggest that good results are obtained with RSA in type 3. In type 4, RSA should be considered as a first option.

Keyword

proximal humeral fractures; postoperative complications; reverse shoulder arthroplasty

MeSH Terms

Arthroplasty
Arthroplasty, Replacement*
Classification
Congenital Abnormalities
Dislocations
Hand
Humeral Head
Humerus*
Neck
Necrosis
Osteotomy
Postoperative Complications
Prostheses and Implants
Rotator Cuff
Shoulder Fractures
Shoulder*
Transplants

Figure

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  Figure 1 (A) Percutaneous pinning after closed reduction. (B) Closed reduction and internal fixation with an intramedullary nailing. (C) Open reduction with locking plate and screw. (D) Hemiarthroplasty.

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  Figure 2 (A) Twenty-five years after a conservative treatment (type 1 cephalic necrosis). (B) Five years after an open reduction and internal fixation with K-wires and roll wire (type 1 cephalic necrosis). (C) One year after a closed reduction and internal fixation with an intramedullary nailing (type 1 cephalic necrosis).

• 

  Figure 3 Proximal humerus fracture sequelae according to Boileau et al.26): (A) type 1 cephalic collapse or necrosis; (B) type 2 locked dislocation or fracturedislocation; (C) type 3 surgical neck nonunion (D) type 4 severe tuberosity malunion.

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  Figure 4 (A) A fracture of proximal humerus after a fall down. (B) Three-dimensional computed tomography reconstruction. (C) Closed reduction and internal fixation with an intramedullary nailing.

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  Figure 5 (A) One year after a closed reduction and internal fixation with an intramedullary nailing (type 1 cephalic necrosis). (B) Hemiarthroplasty. (C) One year after an operation X-ray and forward elevation 140°.

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  Figure 6 (A) Dislocation at 3 months after arthroscopic rotator cuff repair and Bankart repair. (B) Type 2 locked dislocation and loss of glenoid in 3-dimensional computed tomography. (C) Six months after reverse total shoulder arthroplasty with autogenous bone graft.

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  Figure 7 (A) One year after conservative treatment (type 3 surgical neck nonunion). (B) Open intramedullary nailing with autogenous bone graft and locking sutures (hot air balloon technique). (C) Six months after an operation.

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  Figure 8 (A) Comminuted fracture of proximal humerus after a fall down. (B) Hemiarthroplasty. (C) Two years after an operation (type 4 severe tuberosity malunion). (D) Reverse total shoulder arthroplasty.

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