Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont

Abstract

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the '50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.

Keywords: elderly; osteoporosis; proximal humeral fractures; reverse shoulder arthroplasty; shoulder hemiarthroplasty.

Figure 1.

An emblematic case to explain how hemiarthroplasty malpositioning compromises the relationships between the prosthetic head and the tuberosities. a) Preoperative radiogram of a 4-part fracture in a 72-year old lady, treated with hemiarthroplasty. b) Postoperative control showing the excessive height of the prosthetic head (line) Periprosthetic tuberosity reconstruction is correct, but inevitably too low (arrow) in relation to the head.

Figure 2.

a) Tuberosity resorption and cuff failure with subacromial migration of the prosthetic head four years after hemiarthroplasty in a 77-year old woman. b) Severe limitation (less than 90°) of shoulder elevation, with active motion relying mostly on the scapulo-thoracic joint.

Figure 3.

Drawing that illustrates how the center of shoulder rotation shifts medially passing from hemiarthroplasty to reverse total shoulder arthroplasty.

Figure 4.

a) Radiogram of a reverse total shoulder arthroplasty one month after surgery in a 73-year old woman. b) Follow up at 6 years: scapular notching and a large inferior osteophyte of the scapular neck are evident (circle).

Figure 5.

a) Reverse total shoulder arthroplasty implanted for a complex fracture of the proximal humerus in a 76-year old woman. Comminution of the greater tuberosity did not allow an optimal periprosthetic reconstruction (arrow). b) X-rays taken two years after surgery, showing partial resorption of the tuberosity (arrow). c) Shoulder function two years after surgery: active elevation and external rotation are excellent, despite the radiographic findings.