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PubMed2006

[Cadaveric study of the anatomical relationship between the greater tuberosity and prosthetic fin in humeral head replacement].

OBJECTIVE: To investigate the relationship of the greater tuberosity and the lateral fin of the prosthesis by using cadaveric research. METHODS: Nine pairs of fresh-frozen upper extremity specimens (n = 18) were collected. Two-part anatomical neck fracture models were created by osteotomy along the anatomical neck. A standardized humeral head replacement procedure was carried out. The prosthesis was implanted in 20 degrees and 40 degrees of retroversion respectively, and the distance between the bicipital groove and lateral fin of the prosthesis was measured. RESULTS: The lateral fins of prostheses in all specimens were located behind the bicipital groove. The average distances were 7.3 mm in 20 degrees retroversion and 4.0 mm in 40 degrees retroversion. CONCLUSION: It is better to fix the greater tuberosity over the lateral fin during humeral head replacement.

Arthroplasty, Replacement↗
PubMed2006

Re-attachment of the tuberosities of the humerus following hemiarthroplasty for four-part fracture.

This study evaluated the effect on movement under load of three different techniques for re-attachment of the tuberosities of the humerus using test sawbones. In the first, the tuberosities were attached both to the shaft and to each other, with one cerclage suture through the anterior hole in the prosthesis. The second technique was identical except for omission of the cerclage suture and in the third the tuberosities were attached to the prosthesis and to the shaft. An orthogonal photogrammetric system allowed all segments to be tracked in a 3D axis system. The humeri were incrementally-loaded in abduction, and the 3D linear and angular movements of all segments were calculated. Displacement between the tuberosities and the shaft was measured. The first and second techniques were the most stable constructs, with the third allowing greater separation of fragments and angular movement. Separation at the midpoint of the tuberosities was significantly greater using the latter technique (p < 0.05). The cerclage suture added no further stability to the fixation.

Arthroplasty, Replacement↗
PubMedDate not supplied

Humerus varus: a complication of neonatal, infantile, and childhood injury and infection.

Sixteen cases of humerus varus consequent to proximal humeral fracture and osteomyelitis are described. A similar, but variably severe pattern of progressive deformity occurred in all cases. The medial region of the proximal humeral physis usually either developed slowly or failed to develop, whereas the lateral region developed more normally. This caused progressive angular rotation of the proximal humeral epiphysis and physis, so that the lateral region of the growth plate, in its most severe expression, was almost aligned with the longitudinal axis of the shaft. In the majority of the cases, there was a medial-metaphyseal lucency and adjacent medial-osseous bridge. In some cases, a flattened epiphysis and central bridge were present, with less varus deformation with progressive growth. Shortening of the humerus occurred in all cases. Functional impairment, usually a mild to moderate limitation of glenohumeral abduction, was infrequent, even when the dominant arm was involved. Axial lengthening may yet be undertaken. Surgical realignment with a corrective (valgus) osteotomy of the proximal humerus does not, however, appear functionally necessary for all patients.

Birth Injuries↗
PubMedDate not supplied

Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus.

Thirty-nine consecutive patients with 3- and 4-part proximal humeral fractures and fracture dislocations were treated with hemiarthroplasty. After an average of 42 months (range 5 to 98 months) of follow-up, 17 women and 8 men (average age 64.5 years) were evaluated with the University of California-Los Angeles (UCLA) scale, the Constant-Murley scale, the Hospital for Special Surgery (HSS) scale, and the visual analogue scale. Fair, good, or excellent results were achieved in 80% of the patients on the UCLA and Visual scales, in 72% of the patients on the HSS scale, and in 44% of the patients on the Constant-Murley scale. The highest correlation was between the HSS score and the Visual analogue score. According to the UCLA and Constant-Murley results, the outcome after early (<4 weeks) humeral head replacement was significantly better than after late (> or =4 weeks) humeral head replacement (UCLA score, P=.02; Constant-Murley score, P=.01). After early hemiarthroplasty active forward flexion was significantly better (P=.035). Thus the decision to perform prosthetic humeral head replacement in elderly patients should be made as early as possible after trauma.

Aged↗
PubMedDate not supplied

Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus.

The purpose of this study was to evaluate the results of hemiarthroplasty for displaced proximal humeral fractures and to assess clinical and radiologic parameters that could explain unsatisfactory results. Sixty-six consecutive patients (45 women and 21 men) with a mean age of 66 years (range, 31-85 years) were followed up postoperatively for a mean of 27 months (range, 18-59 months), both clinically and radiologically. Subjectively, 29 patients were very satisfied, 9 were satisfied, and 28 were unsatisfied. Postoperative active elevation averaged 101 degrees +/- 33 degrees, external rotation averaged 18 degrees +/- 15 degrees, and internal rotation averaged the L3 level (+/-3 vertebrae). The absolute Constant score averaged 56 of 100 points (range, 20-95 points). Initial tuberosity malposition was present in 18 patients (27%). Tuberosity detachment and migration were noted in 15 patients (23%). Tuberosity migration could be observed after initial tuberosity malpositioning, as well as after initial correct positioning. Final tuberosity malposition occurred in 33 patients (50%) and correlated with an unsatisfactory result, superior migration of the prosthesis, stiffness or weakness, and persistent pain. Factors associated with failure of tuberosity osteosynthesis were poor initial position of the prosthesis (specifically, excessive height and/or retroversion), poor position of the greater tuberosity, and women over age 75 years (likely with osteopenic bone). Techniques to improve tuberosity osteosynthesis, including modifications to current prosthetic design and instrumentation to allow for a more anatomic reconstruction, should lead to more predictable and satisfactory results.

Adult↗
PubMed2005

Reliability and reproducibility of radiographs of greater tuberosity displacement. A cadaveric study.

BACKGROUND: Classification of fractures of the greater tuberosity has shown poor reliability, in part as a result of an inability to assess fracture displacement accurately. We used fluoroscopic images of prepositioned osteotomized greater tuberosity fragments in cadavers to determine the accuracy of radiographic interpretation, the interobserver reliability, and the effect that radiographs might have on surgical decision-making. METHODS: Twelve osteotomies of the greater tuberosity (three each with 2, 5, 10, and 15 mm of displacement) were created in whole-body cadavers. Six fluoroscopic images (anteroposterior views in external and internal rotation, anteroposterior views in neutral rotation with 15 degrees of cephalic and 15 degrees of caudal tilt, a lateral outlet view, and an axillary view) were made after each osteotomy. Four experienced orthopaedic surgeons measured displacement in millimeters on seventy-two randomized images. Four views in sequence (the anteroposterior view in internal rotation and the outlet view together, then the axillary view, and then the anteroposterior view in external rotation) of each osteotomy pattern were then viewed, and each surgeon was asked whether surgery would be indicated on the basis of each set of images. RESULTS: No one fluoroscopic view was significantly more accurate than another. There was a trend toward increased accuracy of imaging of minimally displaced (</=5 mm) tuberosity fragments with the anteroposterior view in external rotation. When viewed sequentially, the anteroposterior view in external rotation, evaluated last, altered treatment in nine of forty-eight situations. There was substantial agreement (kappa = 0.71) among the surgeons with respect to their recommendations for treatment of the displaced greater tuberosities after they had inspected the four images. CONCLUSIONS AND CLINICAL RELEVANCE: To our knowledge, we are the first to examine the accuracy and reliability of interpreting images of known displacements of the greater tuberosity. Multiple radiographic views are needed to evaluate displacement of the greater tuberosity appropriately. The anteroposterior view in external rotation can profile the greater tuberosity and help demonstrate small displacements. Treatment decisions should be consistent between surgeons when multiple views are used.

Cadaver↗
PubMed1991

Shoulder arthroplasty in complex acute and chronic proximal humeral fractures.

From 1983 to 1988, 42 shoulder arthroplasties were performed on comminuted acute or chronic proximal humeral fractures. Patients were categorized according to the post-fracture operative delay; there were 15 four-part fractures, with median post-fracture delay of 13 days (range: 7 to 21), and 27 chronic fractures, including 11 four-part fractures, 9 three-part fractures, and 7 two-part fractures, with median post-fracture delay of 14 months (range: 4 to 72). Follow up was approximately 2 years in both groups (range: 1 to 5). All patients were evaluated according to a modified Neer score-system and classified into four groups. Pain relief was satisfactory in the acute group, but was unpredictable in the chronic group. The results in the acute group were significantly superior (P less than .05). In the acute group, 3 (20%) patients had an excellent result and 6 patients (40%) had a good result, compared to a good result obtained by 6 patients (22%) in the chronic group. Two patients (13%) in the acute group and 11 patients (40%) in the chronic group had a poor result. There were no statistical differences between two-part, three-part, or four-part fractures in the chronic group. Five cases of persistent instability were seen in shoulders formerly treated with osteosynthesis (one acute and four chronic cases). Two of these cases developed an infection. Good results can be expected after prosthetic replacement in acute proximal humeral fractures. Failed primary treatment reduces the possibility of a good result with revision arthroplasty.

Adult↗
PubMed2002

[The BEHAC nail--a new intramedullary implant for managing 2-stage fractures of the humerus].

The BEHAC-nail is a new implant for the treatment of complex humeral fractures, particularly for segmental fractures. It is an elastic intramedullary implant that is inserted retrograde into the distal humerus. The special feature of this nail is its proximal "loop design" which reduces the implant penetration at the proximal fixation site in the subchondral area of the humeral head in comparison to implants with tips such as Rush pins or Hackethal's nails. Thus, the risk of nail migration and perforation of the humeral head is less with the BEHAC-nail than with other nails. Another advantage of the "loop design" is that the humeral head fragment can be fixed adequately. Even short proximal fragments can be stabilized with this design. In contrast a short humeral head fragment cannot be held with implants like the UHN, HVN or Seidel's nail. The BEHAC-nail is a useful implant for segmental fractures of the humerus.

Equipment Design↗
PubMed2000

[Proximal and distal humerus fractures in advanced age].

In contrast to distal humeral fractures, humeral head fractures represent a common injury to the old patient. For both fracture localizations osteoporosis and multi-morbidity are of significant importance. The classification for humeral head fractures in one-, two-, three- and four-part fractures is generally accepted. Valgus impacted head fractures as well as head-splitting fractures are considered a separate entity. In none or minimally displaced fractures good functional results are achieved by conservative means. Although numerous therapeutical procedure are offered in the treatment of displaced fractures of the proximal humerus the result are often disappointing. Generally, minimal invasive surgical procedures should be preferred. However, in dislocated multi-part fractures a primary humeral head replacement is often the treatment of choice. In patients with multifarious morbidity a conservative treatment is always to be included into the therapeutical considerations. Distal fractures of the humerus are classified into extraarticular, intraarticular uni-condylar and intraarticular bi-condylar fractures. The therapeutical recommendations, also in the elderly, is relatively homogeneous: primary open reduction and internal fixation (ORIF) should be carried out aiming for an early postoperative functional treatment. Depending from soft tissue conditions and accompanying injuries the functional results are often good or moderate and are generally comparable to those of younger patients. Following a correct indication for surgical intervention the main priority for both distal and proximal humeral fractures is an early definitive surgical treatment.

Aged↗
PubMed1997

Biomechanical comparison of intramedullary and percutaneous pin fixation for proximal humeral fracture fixation.

OBJECTIVES: The purpose of this study was to investigate the mechanical strength and durability of intramedullary nailing (IM) and percutaneous pinning (PP) for fixation of three-part proximal humeral fractures using a cadaveric model. DESIGN: Three-part surgical neck fractures were created in paired embalmed cadaveric humeri. Fractures were fixed with IM and PP fixation. The fixation stiffness and durability was assessed under cyclic rotational loading (infraspinatus) ramping from 0.1 to 1.25 Newton-meters for 10,000 cycles. The specimen were then torsionally loaded to failure. SETTING: Mechanical testing was performed using a servohydraulic test system (MTS, Minneapolis, MN, U.S.A.). INTERVENTION: PP fixations were accomplished using standard multiplane techniques. IM fixation was attained using an 11.0-millimeter-diameter curved rod interlocked proximally with three splayed 5.0-millimeter cancellous screws and distally with three 3.5-millimeter cortical screws. MAIN OUTCOME MEASUREMENTS: During cyclic loading the reconstruction stiffness, angular migration, and angular displacement per cycle were measured and compared between fixation methods. The ultimate torque at failure, absolute angular migration, and reconstruction stiffness during failure were recorded and compared between fixation methods during destructive testing. RESULTS: The intramedullary device had greater stiffness and less angular displacement of fragments during cyclic loading. When loading the reconstructions to failure, the intramedullary device proved to have greater failure torques, stiffness, energy absorbed, and angular displacement before failure. CONCLUSIONS: This biomechanical study showed that the IM device provided a stronger, more stable, and durable fixation option than did PP fixation for large-fragment multipart proximal humeral fractures with minimal comminution.

Biomechanical Phenomena↗