charles s. neer, 1955 - orthopaedic trauma association€¦ · france charles s. neer ... vs...

ASES-OTA2017SanDiego,CA

P. Boileau-HemiarthroplastyorReverseShoulderArthroplastyforProximalHumerusFractures

1

HemiarthroplastyorReverseShoulderArthroplasty ForProximalHumerusFractures

PascalBoileau,MD

France

CharlesS.Neer,1955

"…resultsofhemiarthroplastyforacuteproximalhumerusfracturesaregood…"

Noaverageresults(Ruleof‘allornothing’)

HAforFx=UnpredictableResults

vs

Boileauetal.,JSES2002



2

2002

GTdisplacementàPoorfuncLonaloutcomes

• IniLalMalposiLon 35%

•MigraLon 24%

• Nonunion/Malunion53%

TuberosityComplicaLons

Boileauetal.,JSES2002

=50%!!

• ImproperProsthesisPosiLoning

• PoorProstheLcDesign

• PoorSutureFixaLonTechnique

• ImproperPost-opManagement

TheProblems



3

Krishnanetal.,TSES2005

Too Proud àGTpullout/migraLon

Restoration of the Gothic arch

ProsthesisMalposiLoning

Too Retroverted àGTpullout/migraLon

Boileauetal,JSES2002

ProsthesisMalposiLoning

GT=TooPost...

GT=TooHigh…ortooLow

BoileauetalJSES2002

àGTpullout/migraLon

TuberosityMalposiLoning



4

=ObstacletoGTposiLoning

ExcessofMetal+++

=Barrierforbonehealing!...

BulkyProsthesesDon’tHelp!

• Loewetal.,JBJSBr2006

Tuberosityhealing:50%withaFractureProsthesisvs29%withaStandardprosthesis

TypeofProsthesisDoesma]er!

• Krishnanetal.,CORR201158 ConvenGonalProstheses112FractureProstheses

à Useoffracture-specificstemsdidimproveshoulderfuncTonandtuberosityhealingcomparedwithconvenTonalstems

àSeparatefixaLonofGT&LT+++

PoorTuberosityFixaLon

Boileauetal,TSES2002


P.Boileau-HemiarthroplastyorReverseShoulderArthroplastyforProximalHumerusFractures

5

PoorTuberosityFixaLon

4HorizontalCerclages

2VerTcalTensionBandSutures

àCerclages+Tension-Band

Boileauetal,TSES2002

1

2

3

àGTfragmentDetachment!!

OverAgressiveRehabilitaLon

àNeutralRotaLonbrace++

PendulumexercisesONLYforthefirst4weeks

ProtecLonofGTRepair



6

HAforFractures

Howtomaximizeoutcomes?...

Doestheprosthesisma]er?...

TwoTypesofImplants

FracturestemN=30

(1998-2006)

StandardstemN=31

(1991-1997)

2013

61Fractures

Use of a Standard (bulky) Implant

àdecreasedGTadequateposiLoning 52%vs97%p=0.0001

àdecreasedGThealing+++ 45%vs87%p=0.0001

àdecreasedFuncLonaloutcome++ AAE113ºvs136º CS58vs68p=0.0001

Typeofimplantdoesma]er!



7

Patients over 75 years & Women have:

-  Higher rate of tuberosity complications

-  Lower functional results

(Regardlessofthetypeofimplantused)

Reverse prosthesis is probably a betteroption in the elderly (> 75yo) female patients

PaLent’sage&genderalsoma]er!

•  SLllunpredictableresults ‘‘AllorNothing’’

•  Prosthesis/GTmalposiLoning

•  Poortechnique&prostheLcdesign‘‘LowProfile’’fractureProsthesis+++

•  InfluenceofpaLent’sage&Genderpoorresultsintheelderlywomen++++

InSummary HAforAcuteFractures

CanRSAbeanalternaLvetoHA

inelderlypaLents?...



8

Patients > 70 y

Reverse / Aequalis-Fx

> 12 months FU

38 cases 28cases79yo

28cases76yo

RSA HA

Sirveaux&Molé,NiceShoulderCourse2008

ProspecLveRandomizedStudy

RSA 33 months F.U HA 20 Cases 23

122° AFE (p=0,07)

109° 18° Active ER 26°

Sacrum Active IR L3 12 pts Pain 1O pts

FuncLonalOutcomes


4050

607080

90100110

120130

ConstantScore%

AequalisFx RSA

AdjustedConstantScore


RSA:MorePredictableResults



9

Reverse

Hemi

MorePredictableVerylow……verygood

0123456

10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 1600123456

10 20 30 40 50 60 70 80 90 100110120130140150160

AcLveForwardElevaLon

RSA:MorePredictableResults

AcLveForwardElevaLon

DoTuberosiLesHealbe]erinRSA?...

• Lowerinfluenceoftuberosityhealing

(comparedtoHEMI)

HEMI=61%

RSA=83%(CuffJBJS2013)

GTHealinginHA/RSA

GreaterTuberosityhealing

gauthier

Rectangle



10

ComparaLveStudy:HAvsRSA

OTSR2016

HA(N=57) RSA(N=41) PConstant 54 57 NS

Adj.Constant 73% 83% 0.02

AFE 112° 130° 0.01

AER 28° 23° NS

AIR L3 Sacrum 0.03

GTHealing 70% 70% NS

ComplicaLons 24% 10% 0.01

SSV 66% 75% NS

IsAbsenceofTuberosityHealingaProblem

inRSAforFracture?...

GTHealing

AbsenceofGTHealing

AFE AER1 AER2

127° 25° 50°

114° 2° *

15° **

TheImportanceofGTHealing




11

AbsenceofGTTuberosityHealinginRSA

à  PoorExternalRotaLonà DecreasedADLsàDecreasedpaLent’ssaLsfacLon

•  RSAoutcomesaremorepredictable

•  RotatorcuffisnotesenLalforproperfuncLonofaRSA,thedeltoidfuncLonissufficient

•  ImprovedERwhentuberosiLesreconstructed

•  PreservaLonoftherotatorcuffcanhelpmaintainstabilityandulLmatelyimproveshoulderfuncLon

Evidence

SufficentargumentsforNOTExcisingtuberosiLesinRSA

AreResultsbe]erinRSA?...

gauthier

Rectangle

gauthier

Rectangle

gauthier

Rectangle



12

HA RSA 63 ASESscore 6558 Constantscore 55108° AcLveAE 118°30° AcLveER 20°

30%(26%tub) ComplicaLons 10%5.7% ReoperaLon 5%

2015

èMeta-analysis:30studies(2004-2014,min.1yFU)

ComparaLveStudy:HAvsRSA

•  AFEismorepredictableinRSAthaninHA,andcomplicaLonrateislower•  But,IRisdecreasedinRSA

•  GThealingisneededtorestoreacLveERandimprovesADL++

à TuberosiLesinRSAshouldNOTbeexcised,butrepaired+++

InSummary RSAforAcuteFractures

Take-HomeMessages



13

GTHealingisNeededinHA

In order to get good functional outcomes

3y po Preop

iscatastrophic!!....

AbsenceofGTHealinginHA

GTHealingisNotNeededinRSABut,tuberosityhealingimproves:

-  Constantscore-  AcTveER++-  ADLs

gauthier

Rectangle



14

HEMIwithtuberosity

problems

RSA

HEMIwithtuberosiLesOK

ThreePostopSituaLons

ARSAwithoutERmusclesisabadRSA!

AbsenceofGTfixaLon/healing:-  Hornblowersign/LagSign-  DecreasedADLs-  IncreasedHumeralloosening

àNOTuberosityexcision+++

ProsthesisDesign&SurgicalTechniqueDoma]erforbothHA/RSA

gauthier

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gauthier

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15

PaTent’sAge(>75)Women(osteopenia+++)Poorbloodsupply(Diabetes,smoking)PoorcompliancewithRehabilitaTon(DemenLa)

GreaterTuberositycomminuTonPoorbonequality(corLcalthickness)CombinedHumerus&Glenoidfracture

PrexisTngRotatorCuffpathology(upto5%)SevereFanyinfiltraTonofRCmuscles(Goutallierstage3or4)

IndicaLonsforRSAinAcuteFractures

charles s. neer, 1955 - orthopaedic trauma association€¦ · france charles s. neer ... vs...

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