Shoulder fractures are common injuries among the elderly, but the management of these fractures can be challenging for physicians. Treatment options include nonoperative modalities, osteosynthesis, and arthroplasty, but patients can still suffer from substantial pain and functional impairment even after receiving these interventions. Nonunions have been frequently linked to bone loss, poor bone quality, and soft-tissue contractures.
“In previous studies, surgeons have had difficulty achieving fracture union with internal fixation and bone-grafting treatments in patients with proximal humeral fracture nonunions,” explains Thomas R. Duquin, MD. “As an alternative, unconstrained shoulder arthroplasty has been advocated for treating these nonunions. Unfortunately, research has documented high rates of unsatisfactory results with arthroplasty, especially with regard to functional outcomes.”
Study Results on Proximal Humeral Nonunions
In the Journal of Bone and Joint Surgery, Dr. Duquin and colleagues recently had a study published that reviewed the results and complications of conventional anatomic shoulder arthroplasty for proximal humeral nonunions. The study also identified factors associated with success or failure. From 1976 to 2007, 67 patients who underwent unconstrained shoulder arthroplasty for proximal humeral nonunions were followed for more than 2 years. The study included 49 women and 18 men with an average age of 64 and a mean duration of 9 years follow-up. Fracture type was assessed according to the Neer rating classification. There were two-part fractures in 36 patients, three-part fractures in 16 patients, and four-part fractures in 15 patients. Hemiarthroplasty was performed in 54 individuals, and total shoulder arthroplasty was done in 13.
According to findings, there were 33 excellent or satisfactory results based on a modified Neer rating classification (Figure 1). “For recipients of shoulder arthroplasty, there was a significant reduction of pain and improvement in shoulder motion when compared with the preoperative state,” says Dr. Duquin (Figure 2). “However, more than half of patients had an unsatisfactory result because of persistent pain or limited function when assessed at follow-up. The unsatisfactory outcomes were largely due to limited shoulder motion.”
Poor outcomes were observed in patients who had a rotator cuff tear at the time of the arthroplasty and nonunion of the tuberosities at the time of follow-up. No patient factors or surgical techniques were identified as positive prognostic indicators in the analysis. Tuberosity healing occurred in 35 shoulders but was inconsistent and influenced the functional outcome. Healing of the tuberosities was achieved in only about half of the study group participants. “Tuberosity healing is important with regard to functional outcome,” Dr. Duquin says. “It’s challenging to achieve anatomic healing of the tuberosity fragments in this patient population.”
Considering Alternatives: Reverse Shoulder Arthroplasty
According to Dr. Duquin, the high rate of tuberosity nonunion or resorption and the link of this to limited functional outcome highlight the need to consider alternatives to conventional anatomic shoulder arthroplasty for proximal humeral nonunions. Results have varied considerably with regard to open reduction and internal fixation with bone-grafting of proximal humeral nonunions in other studies. Conversely, some recent investigations on intramedullary bone-grafting and rigid fixation have demonstrated union rates that exceed 90%.
“For recipients of shoulder arthroplasty, there was a significant reduction of pain and improvement in shoulder motion when compared with the preoperative state.”
“Current research suggests that open reduction and internal fixation with bone-grafting outperforms arthroplasty for treating proximal humeral nonunions if there is sufficient bone stock,” adds Dr. Duquin. “Using a reverse shoulder arthroplasty may result in better outcomes for some patients with proximal humeral nonunions.” That said, few analyses have assessed the use of reverse prosthesis for acute fractures and late sequelae of fractures of the proximal part of the humerus. More studies are needed to clarify the indications for, and long-term outcomes of, reverse shoulder arthroplasty for proximal humeral fractures.
More Research on Proximal Humeral Nonunions Needed
The study by Dr. Duquin and colleagues is one of the largest reviews of arthroplasty for managing post-traumatic proximal humeral conditions to date, but more analyses are needed to better characterize results and complications of the procedure for proximal humeral nonunions and the factors associated with treatment successes and failures. “For example, our survivorship analysis revealed excellent longevity of the implants free of revision, but 24 patients with unsatisfactory outcomes did not undergo revision,” says Dr. Duquin. “The reasons for this are unknown, but they likely include both patient factors and a lack of a reliable surgical option to improve outcomes. The hope is that our study will serve as a basis for ongoing investigations to better understand the roles of conventional arthroplasty, open reduction and internal fixation, and reverse shoulder arthroplasty for proximal humeral nonunions.”
Duquin TR, Jacobson JA, Sanchez-Sotelo J, et al. Unconstrained shoulder arthroplasty for treatment of proximal humeral nonunions. J Bone Joint Surg Am. 2012;94:1610-1617. Available at: http://jbjs.org/data/Journals/JBJS/24809/1610.
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