HumeralHeadReplacementforFracture

ISAKOSSHANGHAI2017DanGuttmann,MD

DirectorofShoulder&ElbowSurgerySportsMedicineFellowshipTaosOrthopaedicInstitute

Asst.ProfessorUniversityofNewMexicoShoulderCommitteeISAKOS

TeamPhysicianUSSki&SnowboardTeam

TimothyJ.Lin,MD

SportsMedicineFellowshipTaosOrthopaedicInstituteSantaFe&Taos,NewMexicoUSA

ISAKOSSHANGHAI2017

DisclosureforDanGuttmannMD

Arthrex,PaciraConsultant

DisclosureforDanGuttmannMDandTimothyLinMD

Arthrex,Medacta,Tornier,Breg,DJO,S&N,StrykerInstitutional/FellowshipSupport

SantaFe&Taos,NewMexico

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Acknowledgement(scheduledtogivethistalk)

Leesa M. Galatz, MDMount Sinai Professor of Orthopedics

Leni and Peter May Department of Orthopedic SurgeryIcahn School of Medicine

Mount Sinai Health SystemNew York, NY

Proximal Humerus Fractures

• Challenge! – Technically difficult – Reconstruct normal anatomy – Faced w poor quality bone – Often comminuted fragments – Obtain Tuberosity healing – Restore Cuff function

Evolution of Treatment Concepts• ORIF

• Locking plates, deltoid splitting approach

• Percutaneous Pinning

• Limited indications • Applicable to certain

fracture types • Hemiarthroplasty

• Fracture specific prostheses

• Reverse for fracture

SevereProximalHumerusFractures Reasons Hemi Has a Role

1. Some reported outcomes equivalent 2. Reverse implants more expensive (relative) 3. Complications historically lower!!

• Risk value analysis- Superior outcomes with Reverse evolving • Related to developing technology/Implant design • Related to Surgeon Experience • Related to Patient factors/co-morbidities

HeadReplacementforFracture

• Goals-•Mustbedonecorrectly!!• Restoresofttissueanatomy–Restoreboneanatomy–TuberosityHealing–Fracturespecificstems

ProximalHumerusFracture ProximalHumerusFracture Tuberosity Reconstruction: Vertical Fixation

Is Reverse a Better Option?

• Main criticism- • Tuberosity healing • Solves the problem: • Immediate reconstruction • Stabilize shoulder • Don’t have to wait for

tuberosity healing

Hemiarthroplasty

• Failure of tuberosity healing • Common indication for

reverse TSA!

• Prominent humeral head • Superior instability • Pain!!

Reverse TSA Traditional Indications

• Fracture sequelae – Nonunion – Malunion – AVN – Tuberosity Osteotomy (Boileau, JBJS)

Reverse SR Indications Have expanded

Massive rotator cuff tears in elderlyFailed shoulder (hemi)arthroplasty/GlenoidAcute proximal humerus fractures in elderlyProximal humeral fracture sequelae: malunion & nonunion Risk of rotator cuff deficiency with arthritis Fatty substitution of SSP and ISP > grade 2B2 Glenoid eccentric wear /decenteringChronic dislocation/instabilityProximal humeral bone loss(tumor/trauma)

Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures

Van der Merwe M, Boyle MJ, Frampton CMA, Ball CM; JSES April 2017

Retrospective cohort study

From 1999 to 2014 218 patients underwent RSA and 427 underwent HHR for acute proximal humerus fractures, out of the New Zealand Joint registry records

Post-op outcomes at 6 months and 5 years post-op

Results: RSA pts older (78.2 vs 71.6 years), higher proportion female (90% vs 77%)

No significant difference in revision rate per 100 component-years (0.58 RSA vs 1.16 hemi, P=0.137), 1 year mortality (3.8% vs 3.4% P=0.805)

No difference in 6 month Oxford Shoulder Score (OSS) (29.6 vs. 28.4) or 5 year OSS (37.6 vs 32.7, P=0.078)

Conclusion – No significant difference in functional outcomes or revision rates between RSA and hemi for acute prox humerus fractures

Hemiarthroplasty versus Reverse shoulder arthroplasty:Comparative study of functional and radiological outcomes in the

treatment of acute proximal humerus fracture

Baudi, Campochiaro, Serafini et al.Musculoskeletal Surgery April 2014

Retrospective Cohort Study2008-2012 – 67 Patients treated with HHR or RSA

Evaluated 53 cases with avg follow-up of 27.5 months28 patients (mean age 71.4) treated with HHR

25 patients (mean age 77.3) treated with RSA

Constant, ASES, DASH score, Abduction Strength, ER1, ER2, and X-Rays

RSA HHR

Constant 56.2 42.3ASES 69.3 51.3

DASH 40.4 46.1

Abd Strength 4.3 1.3 lb inER1 3.3 3.7 lb in

ER2 3.2 1.8 lb in

Tuberosity healing rate

84% 37%

Results

Hemiarthroplasty versus reverse shoulder arthroplasty: comparative study of functional and radiological outcomes in

the treatment of acute proximal humerus fractureBaudi, Campochiaro, Serafini et al.

Musculoskeletal Surgery April 2014

ProximalHumerusFractures

37%(Hemi)vs.84%(RSA)tuberosityhealingrate

Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly

International Orthopaedics 2016; Savin, Zamfirova, Ianotti, et al

Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures

The survey also presented five representative cases to assess treatment preferences

205 surgeons responded (114 Shoulder and Elbow/35 Trauma/56 Sports/Other)

Preferred RSA for 4 part fractures in patients over age 65Trended to favor HHR with higher co-morbidities

Surgeons with >11 years of experience more likely to choose HHR for older/high comorbidity pts

RSA not preferred for younger/active patients

Shoulder Hemiarthroplasty for complex humeral fractures: A 5 to 10 year follow-up retrospective study

Musculoskeletal Surgery April 2014; Giovale, Mangano, Roda, Repetto et al.

27 Patients who had HHR btwn 2001 & 2005 for 3 & 4-part humeral Fxs

Evaluated at mean of 7.2 years post-opMean age at surgery was 71.9 years

Results: Implant survival 88.9%At latest f/u: Mean DASH 26.8; Mean SST-12: 6.5; Mean Constant-Murley: 52.4

Tuberosity complication rate and reduction in acromion-humeral distance were negatively related to clinical outcome

Conclusion: HHR outcomes show good results in majority of patients for complex humeral Fxs

Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty

JSES February 2014; Chalmers, Slikker, Mall, Gupta et al

Retrospective Cohort StudyProspectively evaluated patients who underwent RSA for displaced

3- & 4-part proximal humeral fractures

Created age and sex-matched control groups who underwent ORIF or HHR

Results: 27 patients; (9 RSA/9 HHR/9 ORIF); Minimum F/u 1 year

No significant differences in Simple Shoulder Test, ASES, SF-12 scores

More patients achieved > 90 degrees forward elevation after RSA RSA provided more significant cost savings compared with HHR and

ORIF

Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for Proximal Humeral Fractures: A Systematic Review

Journal of Orthopaedic Trauma Jan. 2015; Ferrel, Trinh, Fischer

Studies up until January 2014 reviewedStudies with outcomes reported on human subjects with

at least 1 year follow-up

Conclusions: RSA with better forward flexion 118 vs 108 in HHR

HHR with better ER 30 vs 20 in RSANo significant difference in either ASES (RSA 64.7 Hemi 63) or

Constant Score (RSA 54.6 Hemi 58)

RSA with higher rate of clinical complications (9.6%) but a lower revision rate (0.93%) compared with HHR

Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: The PROFHER Randomized Clinical Trial

JAMA 2015; Rangan, Handoll, Brealey, Jefferson et al

Multicenter RCT PROFHER group (Proximal Fracture of the Humerus Evaluation by Randomization) 32 Centers in UK from 2008-2011 within 3 weeks after proximal humerus Fx involving surgical neck

250 patients, mean age 66, range 24-92 (77% female/99.6% white

114 in surgical group and 117 nonsurgical group Surgery group: Either ORIF or HHR

Results:No significant difference in Oxford Shoulder Score

(39.07 surgical vs. 38.32 nonsurgical) at 2 years

No sig differences at 2 years in mean SF-12 physical component score, complications related to surgery or shoulder fracture requiring secondary surgery, mortality Conclusions: Overall no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years

Trends in Reverse TSA in US

• Reverse Shoulder Arthroplasty in the United States: A Comparison of National Volume, Patient Demographics, Complications, and Surgical Indications

• Westermann et al. Iowa Ortho Journal, 2015 • Epidemiological study of trends of reverse TSA in the US. • In 2011, 66K patients underwent shoulder arthroplasty • 22K were Reverse • 29K were conventional TSA • 15K were hemiarthroplasty

• Between 2002-2011, RSA and TSA increased, hemi decreased

Cost-Utility of RTSA for Proximal Humerus Fractures

• Hemi Arthroplasty Avg cost $7-8,000 • Reverse Avg cost $12-15,000

• Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: a cost-utility analysis

• Nwachukwu et al, JSES, May 2016 • Goal to compare non-op care, HA, and RTSA for proximal

humerus fractures • From payor perspective, RTSA was cost-effective with an

incremental cost-effectiveness ratio of $8100 per quality-adjusted life year

Complications• Bufquin (2007) • 5 neurologic injuries • 3 pain syndrome • 1 dislocation • 1 acromial fracture • 1 periprosthetic fx • 1 deltoid dehiscence

Complications

• Systematic Review- Namdari, et al. JBJS 2013 • 232 RTSA vs 263 Hemi • Outcome scores similar • 4x greater odds of having a complication • Nerve, pain syndrome, infection • Tuberosity malunion/nonunion, notching (89 vs 27%) • Dislocation • Equivalent reoperation rate

Complications

• In Both Hemi and Reverse • Dislocation • Loosening • Tuberosity migration • Superior migration

More common in Reverse • Scapular notching • Dislocation, Acromial Fx, Deltoid

injury

Neurologic injury after Reverse Bufquin-5/Lenarz-1/Reitman-3

Almost unheard of after a hemiarthroplasty

Results

• Hemiarthroplasty • results strongly dependent on

tuberosity healing • Greater ER • More patients with <90 elevation

• Reverse better than Hemi with failed tuberosity healing

Trend of Reverse for Fracture

• Hemi vs Reverse • Overall, results similar (if tuberosity healed) Often pts w poor bone quality • Hemi- results in 2 disparate groups • Reverse finds “middle ground” • Beware Complication Rate!!

ProximalHumerusFractures

• 504Hemiarthroplastiesvs.377RSAs• 3.6yrmeanfollow-up• ASES56vs.75• Forwardflexion21degreesgreaterRSA• Nodifferenceincomplicationrate

ProximalHumerusFractures

• New Zealand Joint Registry • 55 RSAs vs. 313 Hemi • 5 years results superior for RSA • No difference in revision

HHR and LHBT

Proximal humeral fractures treated with hemiarthroplasty:

Does tenodesis of the long head of the biceps improve results?

Soliman OA, Koptan WMT Injury 2013

RCT with 37 patients treated with HHR for 4-part fractures, fracture-dislocations, and head-split fractures

- LHB intact in 18 (Group 1)

- Tenodesis in 19 patients (Group 2) Constant Score

mean of 69.8 group 1

mean of 74.4 group 2

Shoulder pain affected 6 patients in group 1 (33%) and 3 patients in group 2 (15.8%)

Conclusions: Support routinely performing a tenodesis of the LHB during HHR

Issues to Consider

1. What is best for the patient? 2. What is most cost-effective? 3. What about magnitude of complications? Thank you!!

DRG@taosortho.com