Top

Clinical Orthopaedics and Related Research®

Published in:

01-12-2012 | Clinical Research

Hemiarthroplasty for Humeral Four-part Fractures for Patients 65 Years and Older: A Randomized Controlled Trial

Authors: Harm W. Boons, MD, Jon H. Goosen, MD, PhD, Susan van Grinsven, MSc, Job L. van Susante, MD, PhD, Corné J. van Loon, MD, PhD

Published in: Clinical Orthopaedics and Related Research® | Issue 12/2012

Abstract

Background

Four-part fractures of the proximal humerus account for 3% of all humeral fractures and are regarded as the most difficult fractures to treat in the elderly. Various authors recommend nonoperative treatment or hemiarthroplasty, but the literature is unclear regarding which provides better quality of life and function.

Questions/purposes

We therefore performed a randomized controlled trial to compare (1) function, (2) strength, and (3) pain and disability in patients 65 years and older with four-part humeral fractures treated either nonoperatively or with hemiarthroplasty.

Methods

We randomly allocated 50 patients to one of the two approaches. There were no differences in patient demographics between the two groups. The Constant-Murley score was the primary outcome measure. Secondary outcome measures were the Simple Shoulder Test, abduction strength test as measured by a myometer, and VAS scores for pain and disability. All patients were assessed at 12 months.

Results

We found no between-group differences in Constant-Murley and Simple Shoulder Test scores at 3- and 12-months followup. Abduction strength was better at 3 and 12 months in the nonoperatively treated group although the nonoperatively treated patients experienced more pain at 3 months; this difference could not be detected after 12 months.

Conclusions

We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment.

Level of Evidence

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Baron JA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996;18(3 suppl):209S–213S.PubMedCrossRef

Baron JA, Karagas M, Barrett J, Kniffin W, Malenka D, Mayor M, Keller RB. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996;7:612–618.PubMedCrossRef

Bogner R, Hübner C, Matis N, Auffarth A, Lederer S, Resch H. Minimally-invasive treatment of three- and four-part fractures of the proximal humerus in elderly patients. J Bone Joint Surg Br. 2008;90:1602–1607.PubMedCrossRef

Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Molé D. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg. 2002;11:401–412.PubMedCrossRef

Brorson S, Bagger J, Sylvest A, Hrobjartsson A. Diagnosing displaced four-part fractures of the proximal humerus: a review of observer studies. Int Orthop. 2009;33:323–327.PubMedCrossRef

Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley shoulder assessment. J Bone Joint Surg Br. 1996;78:229–232.PubMed

Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–164.PubMed

Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001;72:365–371.PubMedCrossRef

den Hartog D, de Haan J, Schep NW, Tuinebreijer WE. Primary shoulder arthroplasty versus conservative treatment for comminuted proximal humeral fractures: a systematic literature review. Open Orthop J. 2010;4:87–92.

10.

Edelson G, Safuri H, Salami J, Vigder F, Militianu D. Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg. 2008;17:399–409.PubMedCrossRef

11.

Foruria AM, de Gracia MM, Larson DR, Munuera L, Sanchez-Sotelo J. The pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures. J Bone Joint Surg Br. 2011;93:378–386.PubMedCrossRef

12.

Frankle MA, Greenwald DP, Markee BA, Ondrovic LE, Lee WE 3rd. Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures. J Shoulder Elbow Surg. 2001;10:321–326.PubMedCrossRef

13.

Frankle MA, Ondrovic LE, Markee BA, Harris ML, Lee WE 3rd. Stability of tuberosity reattachment in proximal humeral hemiarthroplasty. J Shoulder Elbow Surg. 2002;11:413–420.PubMedCrossRef

14.

Godfrey J, Hamman R, Lowenstein S, Briggs K, Kocher M. Reliability, validity, and responsiveness of the simple shoulder test: psychometric properties by age and injury type. J Shoulder Elbow Surg. 2007;16:260–267.PubMedCrossRef

15.

Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus. Clin Orthop Relat Res. 1975;112:250–253.PubMedCrossRef

16.

Kontakis G, Tosounidis T, Galanakis I, Megas P. Prosthetic replacement for proximal humeral fractures. Injury. 2008;39:1345–1358.PubMedCrossRef

17.

Kralinger F, Schwaiger R, Wambacher M, Farrell E, Menth-Chiari W, Lajtai G, Hübner C, Resch H. Outcome after primary hemiarthroplasty for fracture of the head of the humerus: a retrospective multicentre study of 167 patients. J Bone Joint Surg Br. 2004;86:217–219.PubMedCrossRef

18.

Kralinger F, Unger S, Wambacher M, Smekal V, Schmoelz W. The medial periosteal hinge, a key structure in fractures of the proximal humerus: a biomechanical cadaver study of its mechanical properties. J Bone Joint Surg Br. 2009;91:973–976.PubMedCrossRef

19.

Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg. 2008;17:42–54.PubMedCrossRef

20.

Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: current concepts in classification, treatment and outcomes. J Bone Joint Surg Br. 2011;93:1–11.PubMed

21.

Naranja RJ Jr, Iannotti JP. Displaced three- and four-part proximal humerus fractures: evaluation and management. J Am Acad Orthop Surg. 2000;8:373–382.PubMed

22.

Neer CS 2nd. Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077–1089.PubMed

23.

Neer CS 2nd. Four segment-classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg. 2002;11:389–400.PubMedCrossRef

24.

Nguyen TV, Center JR, Sambrook PN, Eisman JA. Risk factors for proximal humerus, forearm and wrist fractures in the elderly men and women: the Dubbo Osteoporosis Epidemiology Study. Am J Epidemiol. 2001;153:587–595.PubMedCrossRef

25.

Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20:1025–1033.PubMedCrossRef

26.

Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87–92.PubMedCrossRef

27.

Price D, Bush F, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain. 1994;56:217–226.PubMedCrossRef

28.

Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE. Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am. 2003;85:1215–1223.PubMedCrossRef

29.

Roy JS, Macdermid JC, Faber KJ, Drosdowech DS, Athwal GS. The simple shoulder test is responsive in assessing change following shoulder arthroplasty. J Orthop Sports Phys Ther. 2010;40:413–421.PubMed

30.

Saklad M. Grading of patients for surgical procedures. Anesthesiology. 1941;2:281–285.CrossRef

31.

Schai P, Imhoff A, Preiss S. Comminuted humeral head fractures: a multicenter analysis. J Shoulder Elbow Surg. 1995;4:319–330.PubMedCrossRef

32.

Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75:1751–1755.PubMed

33.

Stableforth PG. Four-part fractures of the neck of the humerus. J Bone Joint Surg Br. 1984;66:104–108.PubMed

34.

Stubbs DF. Visual analogue scales. Br J Clin Pharmacol. 1979;7:124.PubMedCrossRef

35.

Tanner MW, Cofield RH. Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res. 1983;179:116–128.PubMedCrossRef

36.

Torrens C, Corrales M, Vilà G, Santana F, Cáceres E. Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma. 2011;25:581–587.PubMedCrossRef

37.

Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002;84:1919–1925.PubMed

38.

Zyto K, Ahrengart L, Sperber A, Törnkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br. 1997;79:412–417.PubMedCrossRef

Title: Hemiarthroplasty for Humeral Four-part Fractures for Patients 65 Years and Older: A Randomized Controlled Trial
Authors: Harm W. Boons, MD
Jon H. Goosen, MD, PhD
Susan van Grinsven, MSc
Job L. van Susante, MD, PhD
Corné J. van Loon, MD, PhD
Publication date: 01-12-2012
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 12/2012
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2531-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Hemiarthroplasty for Humeral Four-part Fractures for Patients 65 Years and Older: A Randomized Controlled Trial

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 12/2012

A Dual-mobility Cup Reduces Risk of Dislocation in Isolated Acetabular Revisions

Report of Breakout Session: Slipped Capital Femoral Epiphysis Management 2011

Fractures in Brief: Olecranon Fractures

Report of Breakout Session: Strategies to Improve Hip Preservation Training

Do Fluoroscopy and Postoperative Radiographs Correlate for Periacetabular Osteotomy Corrections?

Patient Selection Criteria for Periacetabular Osteotomy or Rotational Acetabular Osteotomy