Shoulder hemiarthroplasty for proximal humerus fracture outcomes after more than two decades: A case series

Andrew A. Palosaari; Christopher A. White; Amit Pujari; Evan L. Flatow; Paul J. Cagle

doi:10.1016/j.jorep.2023.100146

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Research Article

2023

:2;

100146

doi:

10.1016/j.jorep.2023.100146

Shoulder hemiarthroplasty for proximal humerus fracture outcomes after more than two decades: A case series

Andrew A. Palosaari, Christopher A. White, Amit Pujari, Evan L. Flatow, Paul J. Cagle

Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 425 West 59th Street, New York City, NY, 10019, USA

∗Corresponding author: Paul J. Cagle. Paul.Cagle@mountsinai.org

Received: 2023-1-14, Accepted: 2023-3-6, Published: 2023-3-24

The Author(s)

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Proximal humerus fractures can be fixed with shoulder hemiarthroplasty when joint preserving strategies are not feasible. Current literature has explored the outcomes of this intervention with short- and mid-term follow-up showing favorable results. However, since humerus fractures can occur in young individuals, it is important that we understand the long-term outlook of this treatment option.

Five patients who had fractures of the proximal humerus underwent shoulder hemiarthroplasty here. At a average follow-up of 24.5 years, all patients were found to have acceptable patient-reported outcomes sustained range of motion, and no patient required a revision procedure. Patients achieved an average of 50°, T12, and 125° for external rotation, internal rotation, and forward elevation, respectively. American Shoulder and Elbow Surgeons, Simple Shoulder Test, Visual Analog Scale scores were 74/100, 8/12, and 2/10 on average, respectively. None of the five patients were found to have infection or wound complications. Radiographs showed that no patient had identifiable humeral lucency or glenohumeral joint inferior or anterior subluxation.

Shoulder hemiarthroplasty is a viable surgical intervention for comminuted proximal humeral fractures. Over the long-term (i.e., >20 years), patients can expect sustained improvements in shoulder range of motion and acceptable function.

Keywords

Shoulder hemiarthroplasty

Fracture

Shoulder

Arthroplasty

Long-term

Patient-reported outcomes

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1 Introduction

Proximal humerus fracture is a common fracture injury accounting for 5% of fractures, only following hip and distal radius fractures.¹ While a large portion of proximal humerus fractures can be treated conservatively, unstable and displaced fractures may require surgery.² These operative treatments range from open reduction and internal fixation to shoulder arthroplasty.³ Although joint preserving strategies are preferred, shoulder hemiarthroplasty has been shown to be a viable treatment option for patients with four-part fractures, dislocations, anatomic neck displacement, and impacted fractures involving the humeral head.⁴^,⁵ When there is a high degree of comminution, hemiarthroplasty has historically been considered a standard treatment option.⁶

Prior research has shown that pain and range of motion (ROM) outcomes are favorable for patients who undergo hemiarthroplasty for humeral fracture (HHF) in the short- and mid-term.⁶ However, shoulder function rarely returns to baseline.⁷^,⁸ Further, complications frequently occur, including tuberosity nonunion, infection, heterotopic ossification, and migration of the humeral head proximally.⁹ To date, limited literature has analyzed long-term outcomes (i.e., >20 years). This case series presents patients who have long-term follow-up, hypothesizing that shoulder functionality and implant survival will be preserved after more than twenty postoperative years.

2 Case series

An Institutional Review Board approved the present study. Patients were identified using Current Procedural Code 23,470 from an institutional database that consisted of 55 hemiarthroplasty procedures, of which 21 were for fixation of proximal humerus fracture. The five patients who were treated with fracture fixation and who had the longest follow-up times with complete patient-reported outcome (PRO) scores were included.

2.1

2.1 Patient cohort

All procedures were performed by a single surgeon who was board-certified and fellowship trained in Shoulder and Elbow. Patient demographic factors, including sex, age at surgery, interval from surgery to final follow-up, and initial presentation were recorded; minimum follow-up time for inclusion was 20 years. All patients in the registry with a final follow-up time <20 years or who underwent another form of shoulder arthroplasty were excluded.

2.2

2.2 Surgical technique

In all cases, a deltopectoral approach was utilized. Tuberosity elements were mobilized and managed with #5 sutures. The implant height and version were determined utilizing the pectoralis, the metaphysis, and the tuberosity fit as reference points. Implant head sizing was based on intraoperative comparison to the available humeral head, radiographic assessment, and intraoperative tension. All implants were cemented. The tuberosities were repaired with cerclage style and vertical suture orientations.

2.3

2.3 Post-operative rehabilitation

Patients were instructed to begin postoperative functional exercises in the form of passive range of motion on postoperative day number one. Passive forward elevation was restricted to 140° and passive external rotation to 40°. At six weeks, patients were instructed to discontinue sling immobilization and begin active range of motion exercises. At 10–12 weeks, patients began an exercise program focusing on strengthening of the rotator cuff, deltoid, and periscapular muscles.

2.4

2.4 Clinical measurements

At follow up, range of motion (ROM) was determined by external rotation (0°–90°), internal rotation assessment, and forward elevation (0°–180°). Internal rotation was determined by the highest vertebral level that could be reached by the patient's hand posteriorly and analyzed numerically as described by Amroodi et al.¹⁰ Three metrics were collected to define PROs, including the American Shoulder and Elbow Surgeon scores (ASES; 0–100), Simple Shoulder Test (SST; 0–12), and Visual Analog Scale scores (VAS; 0–10); a PRO score ≥50% of the allotted measurement index was considered satisfactory as set forth by the authors of this study (i.e., ≥50 ASES, ≥6 SST score, ≤5 VAS). Implant-free survival at final follow-up was defined as patients who required no revision surgery or implant removal following their index procedure. A radiographic analysis of tuberosity state (i.e., healing vs. absorption), humeral loosening, anterior subluxation, and final acromiohumeral interval was completed by a fellowship trained shoulder and elbow surgeon using final radiographic images based on pre-existing definitions.¹¹^,¹² Immediate postoperative images were used to identify if there was inferior subluxation.

3 Results

In total, 5 patients who underwent HHF were included in this study. Three were male and two were female, and all cases were of left shoulders. Patients were an average age of 57.2 (42.2–69.9) years old, and had a mean follow-up time of 24.5 (22.7–28.6) years. Indications for surgery included nonunion anad four-part proximal humerus fractures. See Table 1 for complete patient demographics, follow-up interval, and presentation. Preoperative ROM scores were available for three of the five patients. For these patients, the mean external rotation, internal rotation, and forward elevation were 77° (30°-120°), L1 (Sacrum-T7), and 10° (−30°-10°), respectively. PRO measures were not available preoperatively since the operating surgeon did not include these in their practice until the year 2000 (see Table 2).

Table 1 Patient demographics.

HHF Case	Age (years)	Sex	Follow-up (years)	Shoulder	Presentation
1	52.9	Male	22.8	Left	Four Part Fracture
2	42.2	Male	25	Left	Nonunion proximal humerus fracture
3	61.1	Female	28.6	Left	Four Part Fracture
4	69.9	Female	23.3	Left	Nonunion Proximal Humerus Fracture
5	61	Male	22.7	Left	Four Part Fracture

At final follow-up, none of the patients required a revision procedure, indicating a 100% implant survival rate. All patients saw sustainment or improvement in their ROM scores. The average postoperative ROM improved to 125° (20°-170°), T12 (L2-T7), and 50° (20°-70°) for external rotation, internal rotation, and forward elevation, respectively. On average, patients met clinically satisfactory marks for ASES, SST, and VAS scores, which were 74/100 (23–100), 8/12 (2–12), and 2/10 (0–8), respectively. Case ID #2 did not meet satisfactory postoperative PRO marks for ASES, SST, and VAS scores, and Case ID #3 did not meet a satisfactory postoperative PRO mark for SST score.

Post-operative radiographic imaging was available for four of five of our cases. Case ID #5 had images outside of the hospital's electronic health records which could not be accessed. Due to the duration of time from surgery to follow up and the transition from hard copy to digital radiographs, pre-operative radiographic imaging was not available for any of our cases. Historical hardcopy radiographs were securely destroyed by the hospital system long before the commencement of this study. Overall, tuberosity resorption was apparent in one case, while no humeral lucency, glenohumeral joint inferior subluxation, or anterior subluxation was noted in any case. The average acromiohumeral interval was 9.4 (5.5–11.1) mm. See Table 3 for a complete report of radiographic information and Fig. 1 for a radiographic representation of Case ID #1 and #3 at final follow-up.

Table 2 Pre- and post-operative clinical outcomes.

HHF Case	Forward Elevation (°)		External Rotation (°)		Internal Rotation		ASES	VAS	SST
HHF Case	Pre	Post	Pre	Post	Pre	Post	Post	Post	Post
1	—	170	—	60	—	T8	97	0	10
2	120	120	10	40	L1	L5	23	8	4
3	—	20	—	20	—	L2	50	2	2
4	30	155	−20	70	T7	T7	100	0	12
5	80	160	−30	60	Sacral	T12	100	0	11
Mean ± SD	77° ± 45°	125° ± 62°	10° ± 6°	50° ± 20°	L1	T12	74 ± 35	2 ± 3	8 ± 4

Table 3 Radiographic outcomes.

HHF Case	Inferior Subluxation	Tuberosity Healing	Tuberosity Resorption	Humeral Loosening	Anterior Subluxation	AHI (MM)
1	No	Yes	No	No	No	5.5
2	No	Yes	No	No	No	11.1
3	—	No	Yes	No	No	10.4
4	No	Yes	No	No	No	10.5
5	—	—	—	—	—	—

Anterior-posterior projection radiographic representation of two hemiarthroplasty implants at long-term follow-up. A) Case ID #1 at 22.8 years follow-up with evidence of tuberosity healing and no humeral component loosening. B) Case ID #3 at 28.6 years follow-up with evidence of tuberosity resorption but no humeral component loosening.

4 Discussion

Hemiarthroplasty has increasingly been utilized for the treatment of comminuted proximal humerus fractures. While studies have shown favorable short- and mid-term outcomes for HHF, there are currently no studies reporting long-term outcomes greater than 20 years. This study shows that our patients met clinically satisfactory PROs, on average, at a follow-up of more than two decades after their index procedure. Further, ROM improvements were sustained, no revisions occurred, and complications were minimal.

Before this case series, the longest-term follow-up study examining outcomes after HHF was that of 364 patients who had a average follow-up of 10.6 years from the Danish Shoulder Arthroplasty Registry.¹³ The mean postoperative Western Ontario Osteoarthritis of the Shoulder score for these patients was 64/100, which was deemed acceptable by the authors. Several other studies that report PROs with shorter follow-up yield mixed results when considering our ≥50% of the allotted measurement index as satisfactory rule.⁶^,¹⁴ For example, in a single institutional study of 27 patients who underwent HHF with a mean follow-up of 5.3 years, Disabilities of the Arm, Shoulder & Hand (DASH), SST-12, and Constant-Murley scores had been 27/100, 7/12, and 52/100, respectively.⁶ In this case, patients would have been considered to have met satisfactory marks for the Constant-Murley score, but not the DASH or SST-12 scores. Our patients were found to have satisfactory PROs, similar to the acceptable long-term outcomes found in the Danish Shoulder Arthroplasty Registry.¹³

Pain reports are also inconsistent in the literature. For example, while Kontakis et al. found that at an average of 3.7 years follow-up most of their 808 patients who underwent HHF experienced no pain or only mild pain,⁹ Antuna et al. reported that at 5 years of follow-up in 57 patients who underwent HHF, 16% of patients were in moderate to severe pain and 50% of patients were dissatisfied with the results of the procedure.¹⁵ With an average VAS pain score of 2/10 (0–8) in our cases, we found that patient pain reports were relatively low after two decades. Nevertheless, the aforementioned variability in the literature highlights the importance of preoperative patient counseling that long term pain can be experienced after HHF.

This study found that patient ROM at final follow-up was similiar to that reported in studies with short- and mid-term follow-up. For example, a study of 57 patients who were treated with HHF with an over 5-year follow-up found that mean forward flexion to be 100° degrees and external rotation to be 30° degrees.¹⁵ Similarly, in a study of 808 patients who underwent HHF with an average follow-up of 3.7 years, mean forward elevation was 105.7° and external rotation was 30.4°.⁹ At 44 months follow-up for 29 patients who were treated with HHF, Khurana et al. found a mean forward flexion of 110.4°.¹⁶ Within our study cohort, external rotation, internal rotation, and forward elevation were 125° (20°-170°), T12 (L2-T7), and 50° (20°-70°), respectively. Thus, long-term ROM is comparable to that seen in the short- and mid-term.

Complications of hemiarthroplasty, including subluxation, infection, and heterotopic ossification are well-recognized in the literature.⁹^,¹⁷^,¹⁸ Yet, the rate of these complications remains low in published studies. For example, a study with a 4-year follow-up on 56 patients who underwent HHF from a single institution found that no patient experienced joint dislocation, subluxation, or infection after their operation.¹⁹ Another study of 808 patients who underwent HHF with an average follow-up of 3.7 years found that superficial infection, deep infection, complications related to fixation, heterotopic ossification, and migration of the humeral head proximally occurred in 1.6%, 0.6%, 11.2%, 8.8%, and 6.8% of patients, respectively.⁹ The present study also found low complication rates. While tuberosity resorption was apparent in one patient at long-term follow-up of 28.6 years, no established diagnoses of infection or instability were noted in any of the cases.

Revision rates are a marker of long-term success of arthroplasty. A previous study of 364 HHF patients with an average follow-up time of 10.6 years found a 14-year cumulative revision rate was 5.7%.¹³ When considering a larger subset of data on 2750 hemiarthroplasties from the same dataset, the authors found that implant survival rate at 10 years was 95%.²⁰ A study of the Danish Shoulder Arthroplasty Registry of 644 HHF patients with an average follow-up time of 3.7 years found a revision rate of 7% at the time of the study.²¹ Similarly, Giovale et al. showed that for 27 HHF patients who had a follow up of 5–10 years, implant survivability was 88.9%.⁶ Among the present cases, no revisions occurred indicating the long-term survivability of the hemiarthroplsty implant for this indication.

With a mean follow-up of 24.5 years, this case series is the longest-term follow-up analyses to date for patients undergoing HHF. While we have seen favorable results, multiple limitations of this case series need to be addressed. The primary limitation of this study is the small sample size. Further, we lacked preoperative PROs, preoperative ROM scores were incomplete, and radiographic data was only available for four of our five patients. Future studies would benefit from an expanded sample size to more concretely define patient expectations for the long-term. This research group intends to provide further clarification towards this point as the remaining 16 patients in the institutional database return for their >20-year follow-up appointments.

5 Conclusion

This single surgeon case series reports the longest-term outcomes of patients undergoing HHF to date. At an average of greater than two decades follow-up, we found patients to have acceptable patient-reported outcomes, sustained ROM, and no patient requiring a revision procedure. Treatment of proximal humeral fracture with hemiarthroplasty is a viable long-term surgical option.

Funding

No funding was received from any grant from any funding agency in the commercial, non-profit, or public sector.

Patients consent

Patients whose cases are described in our study consented to our use of their medical information.

Institutional ethical committee approval

Our institution's institutional review board (IRB) approved this study.

Authors contribution

• Author 1 –Data collection, formal analysis, investigation, methodology creation, original manuscript drafting, critical review & editing.

• Author 2 – Conceptualization, data collection, investigation, methodology, original manuscript drafting, critical review & editing, figures.

• Author 3 – Original manuscript drafting, critical review & editing, resources, critical review & editing.

• Author 4 – Conceptualization, investigation, methodology, project administration, resources.

• Author 5 – Conceptualization, investigation, project administration, resources, critical review, validation, visualization.

Disclosures

Paul J. Cagle, MD.

Stryker: Consultant.

Johnson & Johnson: Consultant.

Arthrex: Consultant.

Evan L. Flatow, MD.

American Shoulder and Elbow Surgeons: Board or committee member.

Health Association of NY: Board or committee member.

Innomed: IP royalties.

Springer: Publishing royalties, financial or material support.

Zimmer: IP royalties; Unpaid consultant.

The following individuals have no conflicts of interest or sources of support that require acknowledgement: Andrew A. Palosaari, Christopher A. White, Amit Pujari.

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