American Academy of Orthopaedic Surgeons Annual Meeting

American Academy of Orthopaedic Surgeons Annual Meeting

Issue: July 2011
July 01, 2011
3 min read
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Reverse shoulder fracture prosthesis aids return to function and tuberosity healing

Issue: July 2011
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SAN DIEGO — Investigators from France and the United States showed that a reverse shoulder prosthesis designed for treating acute proximal humeral fractures, particularly in an elderly population, improved on results with standard prostheses.

Pascal Boileau, MD, of Nice, France presented the results of a prospective study at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Surgeons used the implant in 32 consecutive displaced proximal humeral fractures, which they said produced tuberosity healing in all but one case based on radiologic results. The non-healed case had partial lysis, and the implant started to migrate by 5 months postoperatively.

“The reverse fracture prosthesis gives the best chance to obtain tuberosity healing in elderly patients despite frequent osteopenic bone. Obtaining tuberosity healing is important to restore external rotation — crucial for all activities of daily living — but also to avoid complications such as instability or infection,” he told Orthopedics Today.

Approach

Discussing the implant, Boileau said, “We adapted the design of the Aequalis (Tornier, Inc.) fracture prosthesis to the Aequalis reverse shoulder fracture prosthesis (Aequalis Reverse Fx).”

Most cases that used the reverse shoulder fracture prosthesis was involved four-part fractures. However, there were five fracture dislocations and two glenoid fractures in the series.

Thirty-one patients were operated on via a transdeltoid superior approach at about 7 days post-injury. Most of the patients were about 80 years old. Patients received a cancellous bone graft harvested from the fractured humeral head, and surgeons replicated the tuberosity synthesis approach involving horizontal cerclages combined with vertical suture tension bands that they used with Aequalis’ non-reverse shoulder fracture prosthesis model.

“We use a standardized technique of tuberosity fixation with double-looped sutures and a special knot — the “Nice knot” — that allowed [us] to give a very strong fixation,” he said.

Satisfied patients, better function

At final follow-up mean Constant scores were 62 points, with a 92% adjustment of the results for age and gender.

“What it important is the radiological and CT scan results,” Boileau said, noting all 15 patients who had more than 6-months follow-up underwent CT-scans at 6 and 12 postoperative months. “The patients were mainly satisfied,” he said.

Investigators observed tuberosity healing in 14 of the 15 patients with extended radiographic and CT-scan follow-up. Patients had no implant or surgical-related complications based on the results. – by Susan M. Rapp

Reference:
  • Boileau P, Moineau G, Brassart N. Proximal humeral fractures in the elderly: Outcome after reverse shoulder fracture prosthesis (RSFP). Paper #85. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 15-19. San Diego.
  • Pascal Boileau, MD, can be reached at Department of Orthopaedic Surgery & Sports Traumatology, 151, Route de St. Antoine de Ginestière, 06202 Nice, France; 334-9203-6497; email: boileau.p@chu-nice.fr
  • Disclosure: Boileau receives royalties from Tornier and is a paid consultant to Smith & Nephew.

Perspective

This study highlights an emerging role for reverse arthroplasty in the treatment of proximal humerus fractures. Patients treated with traditional hemiarthroplasty for fracture typically fall into one of two categories; those with excellent motion and those with very poor motion. Reverse arthroplasty (RSA) has the theoretical advantage of allowing forward elevation despite deficiency of the rotator cuff either due to a tear or tuberosity nonunion. Following fracture, RSA seems to provide more consistent restoration of elevation with fewer patients experiencing either extreme, ie, fewer very poor and fewer excellent results.

Highlighted in this study is the need to reconstruct the tuberosities when using RSA for fracture because without them, rotation in either direction is poor, as is the outcome despite reasonable elevation. The authors used bone grafting in all cases which likely improved tuberosity healing in this elderly and likely osteoporotic population. They had successful healing in all but one patient and universal patient satisfaction.

— Evan L. Flatow, MD
Lasker Professor and Chair , Chief of Shoulder Surgery Leni & Peter W. May Department of Orthopaedic Surgery
Mount Sinai School of Medicine, New York
Orthopedics Today Editorial Board member
Disclosure: He has no relevant financial disclosures.