论文研究-老年人肱骨头粉碎性骨折的原发性髋关节置换术的长期临床和放射学结果：5-10年的随访研究资源-CSDN文库

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Open Journal of Orthopedics, 2019, 9, 165-179

http://www.scirp.org/journal/ojo

ISSN Online: 2164-3016

ISSN Print: 2164-3008

DOI:

10.4236/ojo.2019.98018 Aug. 12, 2019 165 Open Journal of Orthopedics

Long-Term Clinical and Radiological Outcome

in Primary Hemiarthroplasty for Comminuted

Humeral Head Fractures in the Elderly: A 5 - 10

Years Follow-Up Prospective Study

Dagmar Alice Wichelhaus

, Philip Gierer

, Thomas Mittlmeier

, Robert Rotter

Abteilung für Unfall-, Hand- und Wiederherstellungschirurgie, Chirurgische Universitätsklinik Rostock, Rostock, Germany

Abteilung für Unfall-, Wiederherstellungs- und Handchirurgie, Städtisches Klinikum Dresden, Dresden, Germany

Abstract

Objective: In the constantly growing population of people beyond the age of

60 years, the incidence of complex comminuted humeral head fractures increas-

es, thus increasing the need for prosthetic replacement.

The purpose of this

study was to determine the long-

term results after primary hemiarthroplasty in

patients older than 60 years. Methods:

From 08/2010 to 12/2015 a prospective

study of 54 patients (mean age 75 years) with complex humeral head fracture

was performed at the University Hospital Rostock. 24 patients were available for

follow-up after 5 - 10 years. Pain, the Karnofsky-index, and the

range of motion

were obtained as well as radiographs in two planes. The Constant-Murley score

and the UCLA rating system were evaluated for functional assessment. Results:

15 patients were painfree. The Karnofsky index deteriorated from 94 preopera-

tively to 70. The Constant-Murley score of the operated extremity reached 47

points out of possible 100, the uninjured side scored 82 points. The age-specific

Constant-Murley score showed more favorable results. The UCLA rating sys-

tem values leveled up to 22 out of 35 points for the replaced shoulder and 33

points for the other arm. Radiologically, more than 50% of the implan

ts were

classified as non-centered and the acromio-humeral space diminished signif-

icantly. Conclusions: Primary hemiarthroplasty helps to restore a situation of

little or no pain whereas functional and radiological outcome remains li-

mited. Revision surgery or conversion to reverse shoulder arthroplasty

was

not indicated in any case supporting the clinical value of hemiarthroplasty.

Keywords

Primary Hemiarthroplasty, Proximal Humeral Fracture, Prospective Study,

How to cite this paper:

Wichelhaus, D.A.,

Gierer, P

., Mittlmeier, T. and Rotter, R.

(201

9) Long-Term Clinical and Radiologi-

cal Outcome in Primary Hemiarthroplasty

for Comminuted Humeral Head Fractures

in the Elderly: A 5

- 10 Years Follow-

Prospective Study

Open Journal of Orth

pedics

, 165-179.

https://doi.org/10.4236/ojo.2019.98018

Received:

June 25, 2019

Accepted:

August 9, 2019

Published:

August 12, 2019

9 by author(s) and

Scientific

Research Publishing Inc.

This work is licensed under the Creative

Commons Attribution International

License (CC BY

4.0).

http://creati

vecommons.org/licenses/by/4.0/

Open Access

D. A. Wichelhaus et al.

DOI:

10.4236/ojo.2019.98018 166 Open Journal of Orthopedics

Functional Outcome

1. Introduction

A United Nations survey estimates that by 2050, approximately 2 billion people

worldwide have attained a minimum age of 60 years. With age, the risk of os-

teoporosis falls and fractures increases [1] [2]. Remaining functional deficits after

fracture treatment in the elderly often lead to an institutionalization in a nursing

home [3]. Proximal humeral fractures account for 4% - 5% of all fractures in

adults. 30% of these fractures occur in patients older than 60 years mostly after

low-energy trauma and are clearly related to osteoporosis [4]. Older patients

tend to suffer a more complex fracture pattern such as Neer three- or four-part

fractures with dislocation and humeral head-splitting [5]. The optimal treatment

of these fractures has not been clarified conclusively. Even non-surgical treatment

might represent a viable option in defined displaced fracture types of the humer-

al head with an acceptable clinical outcome which is not inferior to that after

surgical intervention [6]. Fracture fixation reaches its limits in the presence of

reduced bone quality, advanced degeneration of the rotator cuff, dislocation or

headsplit. Consecutive failure of fracture fixation with cut-out of the screws and

re-displacement occurs more often than in younger patients. Complications such as

humerus head necrosis also reduce the mid-term postoperative success and call for

a change of therapeutic strategy requiring secondary prosthetic replacement [7].

Even though Charles Neerfirst reported on primary hemiarthroplasty for

humeral head fractures in 1953, fracture endoprothesis is still not considered a

standard operating procedure in clinical practice due to insufficient cuff repair,

tuberosity mal- or non-union, loss of tuberosity reduction and bone resorption

which may contribute to an inferior outcome [7] [8] [9].

In a prospective study, we evaluated the clinical and radiological results 5 - 10

years after primary hemiarthroplasty for displaced and comminuted proximal

humeral fractures in patients older than 60 years. A subpopulation of the study

collective had been examined 1 and 2 years after the implantation of the humeral

head prosthesis [10]. An improved version of modular humeral head prosthesis

was used allowing anatomic reconstruction of the humeral head applying infi-

nitely variable modularity to restore the functional center of rotation and the

humeral offset correctly [11]. The purpose of this study was to evaluate long

term functional and radiological results in primary fracture hemiarthroplasty, to

determine if there are still substantial arguments to use primary hemiarthrop-

lasty, in particular in the knowledge of more recent recommendations for in-

verse arthroplasty in a geriatric population with fractures of the humeral head

[12] [13] [14].

2. Patients and Methods

From August 2000 to December 2005, 54 patients with complex humeral head

D. A. Wichelhaus et al.

DOI:

10.4236/ojo.2019.98018 167 Open Journal of Orthopedics

fractures were treated with primary hemiarthroplasty and were evaluated pros-

pectively. The study was approved by the local ethics committee and the patients

gave their written informed consent to participate in the study. The average age

of the operated patients accounted for 75 ± 10.7 years (range 60 - 92 years). In-

clusion criteria for primary hemiarthroplasty were subjects aged 60 years or

above affected by 4 part fractures with a complex fracture pattern that were con-

sidered not reconstructable due to poor bone stock, fracture dislocation, de-

stroyed humeral articular surface or head-splitting. Exclusion criteria included

circumflex nerve lesion, neurological disorders with palsy of the upper extremity

and injury of the contralateral shoulder or humerus.

The 4

generation of a modular humeral head prosthesis (EPOCA C.O.S.



, Fa.

Argomedical, Gifhorn, Germany) with a double eccentric adjustable headboard

was used in all cases. In this particular endoprosthesis type the posterior and

medial offset can be selected according to the anatomical conditions. The coupling

of head and stem is achieved by an intermediary eccentric frictional cone con-

nector. The tuberosity fragments were reconstructed using braided cable cer-

clages of one millimeter in diameter with a steal lead-wire seal ensuring an ex-

tremely stable reattachment of the tuberosities maintaining a low risk of cut-out

and loss of reduction [11] [15].

2.1. Surgical Technique

Patients were placed in a half-sitting position and received antibiotic prophylaxis

as a single dose. The anteromedial deltoideo-pectoral approach was used. After

exposure of the fracture site, the tuberosities were identified and retracted via 1 -

0 polyester sutures that were passed through the tendon-bone junctions. The

humeral head was extracted and measured to select the matching size of the

prosthetic head. Then the humeral shaft was prepared for stem implantation.

The exact shaft size, depth of implantation, the retroversion angle and the offset

were evaluated by insertion of a trial endoprosthesis. All stems were fixed via

PMMA bone cement. After placing an absorbable blocker into the medullary

cavity of the humeral shaft and application of bone cement (Refobacin-Palacos



Heraeus, Hanau, Germany) with a cement gun, the prosthesis was inserted. The

tuberosities in connection to the rotator cuff were fixed to the prosthesis by

1mm braided cable cerclages as recommended by the developer of the endo-

prosthesis [15].

From day one after surgery a continuous passive motion device mobilized the

shoulder. Additionally, physiotherapy was performed as active assisted exercises

restricted to 90˚ of abduction and elevation while avoiding external rotation for

6 weeks. Weight-bearing was encouraged 6 weeks after the operation.

2.2. Data Collection

Patient data, operative and postoperative complications, general complications,

duration of the surgical procedure and length of stay in hospital were docu-

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