Hemiarthroplasty for Proximal Humeral Fractures: Maximizing Surgical Outcomes

1. Hemiarthroplasty for Proximal Humeral Fractures Christian Veillette M.D., M.Sc., FRCSC Assistant Professor, University of Toronto Shoulder & Elbow Reconstructive Surgery Toronto Western Hospital University Health Network Email: orthonet@gmail.com Maximizing Outcomes

2. The Problem?

3. Systematic Review J Bone Joint Surg [Br] 2008;90-B:1407-13.

4. 12 Randomized studies (n=578) • 8 non-operative • 3 surgical • 1 compared surgical and nonoperative • Heterogeneity prevented data pooling • Unclear whether surgery provides better results • Trend toward better short term function with less pain with hemiarthroplastyvs conservative

5. Can we predict outcome?

6. The Challenge • Anatomic reduction • Stable fixation • Healed tuberosities • Minimal fibrosis

7. Issues Associated with Poor Outcome • Delay in treatment • Nonanatomic reconstruction • Tuberositynonunion • Pre-existing rotator cuff tear • Age > 70?

8. Treatment Goals • Anatomic reconstruction • Early surgery – within days not weeks • Stable fixation • Early, controlled passive motion

9. Surgical Principles • Maintain deltoid origin/insertion • Restore anatomy • Humeral length – GT  Head • Humeral version • Tuberosity position • Stable fixation • Tuberosities to themselves • Tuberosities to shaft

10. Patient Setup Nho S. J. et.al. J Bone Joint Surg 2007:89:44-58

11. Identify Biceps

12. Identify Fracture Lines

13. Traction suture on LT #2 Ethibond @ Bone-tendon interface

14. Extraction of humeral head

15. Traction suture on posterior GT

16. Mark top of Pec major Use as reference point for humeral height

17. Humeral height and version • Height • Humeral head to tuberosity distance (0.5 cm – 1.0 cm) • Top of head = Top of glenoid • Overall humeral length – less important • Version (20o – 40o retroversion) • Epicondylar axis • Anterior fin = bicipital groove

18. Humeral version

19. Humeral height

20. Size humeral head Error on smaller size. Don’t overstuff.

21. Trial reduction

22. Intraoperative fluoroscopy

23. Preparation for tuberosity fixation #2 Ethibond x 2 #2 Ethibond x 2

24. Implant insertion

25. Tuberosity repair • Sutures between tuberosities and implant/fin – set height • Bone tendon junction LT • Bone tendon junction GT • Cerclage suture (medial neck) • Tuberosity to tuberosity x 2 • Shaft to tuberosities x 2 each • Rotator interval • Tenodese biceps

26. Aftercare • Week 1-2 • Shoulder immobilizer • Week 2-6 • Passive ROM • Week 6-12 • AAROM and AROM • Phase 1 strengthening (Week 8) • Week 12 – 24 • Phase 2 strengthening

27. Results • Pain scores usually excellent • Functional scores variable • Quality of anatomic result • Tuberosity fixation/union • Rotator cuff • Patient compliance • Elevation average 120o • Experience • Patient compliance

28. Conclusion • Difficult operation • Results correlate with anatomic result • Humeral height • Humeral version • Tuberosity fixation • Intraoperativexray • Aftercare critical • Usually produces painfree shoulder • Function variable

29. Thank You www.uhnorthopaedics.ca