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Clinical Outcomes of Anatomical Total Shoulder Arthroplasty in a Young, Active Population
Although total shoulder arthroplasty (TSA) has proved to be a reliable solution in older patients, treatment in younger patients with glenohumeral arthritis remains controversial, and there are still few reliable long-term surgical options.1-8 These options include abrasion arthroplasty and arthroscopic management,9,10 biologic glenoid resurfacing,11,12 and humeral hemiarthroplasty with13 or without14,15 glenoid treatment and anatomical TSA.
In the younger cohort, 20-year TSA survivorship rates up to 84% have been reported, and unsatisfactory subjective outcomes have been unacceptably high.16 In addition, there is a paucity of literature addressing the impact of TSA on return to sport. Recommendations on returning to an athletic life style are based largely on surveys of expert opinion17,18 and heterogeneous studies of either older patients (eg, age >50-55 years) who are active19-21 or younger patients with no defined level of activity.5,7,8,16,22-24
To our knowledge, no one has evaluated the short-term morbidity and clinical outcomes within a young, high-demand patient population, such as the US military. Therefore, we conducted a study to evaluate the clinical success and complications of TSA performed for glenohumeral arthritis in a young, active population. We hypothesized that patients who had undergone TSA would have a low rate of return to duty, an increased rate of component failure, and a higher reoperation rate because of increased upper extremity demands.
Materials and Methods
After obtaining protocol approval from the William Beaumont Army Medical Center Institutional Review Board, we searched the Military Health System (MHS) Management Analysis and Reporting Tool (M2) database to retrospectively review the cases of all tri-service US military service members who had undergone primary anatomical TSA (Current Procedural Terminology code 23472) between January 1, 2007 and June 31, 2014. This was a multisurgeon, multicenter study. Patient exclusion criteria were nonmilitary or retired status at time of surgery; primary surgery consisting of limited glenohumeral resurfacing procedure, hemiarthroplasty, or reverse TSA; surgery for acute proximal humerus fracture; rotator cuff deficiency diagnosed before or during surgery; and insufficient follow-up (eg, <12 months, unless medically separated beforehand).
The M2 database is an established tool that has been used for clinical outcomes research on treatment of a variety of orthopedic conditions.25,26 The Medical Data Repository, which is operated by MHS, is populated by its military healthcare providers. The MHS, which offers worldwide coverage for all beneficiaries either at Department of Defense facilities or purchased using civilian providers, is among the largest known closed healthcare systems.
All active-duty US military service members are uniformly required to adhere to stringent and regularly evaluated physical fitness standards, which typically exceed those of average civilians. Routine physical training is required in the form of aerobic fitness, weight training, tactical field exercises, and core military tasks, such as the ability to march at least 2 miles while carrying heavy fighting loads. In addition to satisfying required height and weight standards, all service members are subject to semiannual service-specific physical fitness evaluations inclusive of timed push-ups, sit-ups, and an aerobic event. Service members may also be required to maintain a level of physical training above these baseline standards, contingent on their branch of service, rank, and military occupational specialty. If a service member is unable to maintain these standards, medical separation may be initiated.
Demographic and occupational data were extracted from the database. These data included age, sex, military rank, and branch of service. Line-by-line analysis of the Armed Forces Health Longitudinal Technology Application (Version 22; 3M) electronic medical record was then performed to confirm the underlying diagnosis, surgical procedure, and surgery date. Further chart review yielded additional patient-based factors (eg, laterality, hand dominance, presence and type of prior shoulder surgeries) and surgical factors (eg, surgery indication, implant design). We evaluated clinical and functional outcomes as well as perioperative complications, including both major and minor systemic and local complications as previously described27,28; preoperative and postoperative range of motion (ROM) and self-reported pain score (SRPS, scale 1-10) as measured by physical therapist and surgeon at follow-up; secondary surgical interventions; timing of return to duty; and postoperative deployment history. The primary outcome measures were revision reoperation after index procedure, and military discharge for persistent shoulder-related disability. Clinical failure was defined as component failure or reoperation. Medical Evaluation Board (MEB) is a formal separation from the military in which it is deemed that a service member is no longer able to fulfill his or her duty because of a medical condition.
Statistical Analysis
Continuous variables were compared using statistical means with 95% confidence intervals (CIs) and/or SDs. Categorical data were reported as frequencies or percentages. Univariate analysis was performed to assess the correlation between possible risk factors and the primary outcome measures. P < .05 was considered statistically significant.
Results
Demographics
We identified 24 service members (26 shoulders) who had undergone anatomical TSA during the study period (Table 1). Mean (SD) age was 45.8 (4.5) years (range, 35-54 years), and the cohort was predominately male (25/26 shoulders; 96.2%). Most cohort members were of senior enlisted rank (14, 58.3%), and the US Army was the predominant branch of military service (13, 54.2%). The right side was the operative extremity in 7 cases (26.9%), and the dominant shoulder was involved in 6 cases (23.1%). Two patients (8.3%) underwent staged bilateral TSA. Most patients (76.9%) underwent TSA on the nondominant extremity.
Surgical Variables
TSA was indicated for post-instability arthropathy in 13 cases (50.0%), posttraumatic osteoarthritis in 7 cases (26.9%), and unspecified glenohumeral arthritis, which includes primary glenohumeral osteoarthritis, in 5 cases (19.2%) (Table 2). One case was attributed to iatrogenically induced chondrolysis secondary to intra-articular lidocaine pump. Twelve patients (46.2%) had at least 1 previous surgery. Of the shoulders with instability, 10 (76.9%) had undergone a total of 14 surgical stabilization procedures—10 anterior labral repairs, 2 posterior labral repairs, and 2 capsular plications. The other shoulders had undergone a total of 18 procedures, which included 4 rotator cuff repairs and 3 cartilage restoration procedures.
Clinical Outcomes
Mean (SD) follow-up was 41.0 (21.3) months (range, 11.6-97.6 months). All but 1 shoulder (96.2%) had follow-up of 12 months or more (the only patient with shorter follow-up was because of MEB), and 76.9% of patients had follow-up of 24 months or more (4 of the 6 patients with follow-up under 24 months were medically separated) (Table 3). In all cases, mean ROM improved with respect to flexion, abduction, and external rotation. At final follow-up, mean (SD) ROM was 138° (36°) forward flexion (range, 60°-180°), 125° (39°) abduction (range, 45°-180°), 48° (19°) external rotation at 0° abduction (range, 20°-90°), and 80° (9.4°) external rotation at 90° abduction (range, 70°-90°). Preoperative flexion, abduction, and external rotation at 0° and 90° abduction were all improved at final follow-up. The most improvement in ROM occurred within 6 months after surgery.
Overall patient satisfaction with surgery was 92.3% (n = 24). Ultimately, 18 (72.0%) of 25 shoulders with follow-up of 1 year or more were able to return to active duty within 1 year after surgery, though only 10 (45.5%) of 22 with follow-up of 2 years or more remained active 2 years after surgery. Furthermore, 5 patients (20.8%) were deployed after surgery, and all were still on active duty at final follow-up. By final follow-up, 9 (37.5%) of 24 service members were unable to return to military function; 7 had been medically discharged from the military for persistent shoulder disability, and 2 were in the process of being medically discharged.
In all cases, SRPS improved from before surgery (5.2 out of 10) to final follow-up (1.4). At final follow-up, 22 patients (88.0%) reported mild pain (0-3), and no one had pain above 6.
Complications
Nine patients had a total of 12 postoperative complications (46.2%): 6 component failures (23.1%), 2 neurologic injuries (7.7%; 1 permanent axillary nerve injury, 1 transient brachial plexus neuritis), 2 cases of adhesive capsulitis (7.7%), and 2 episodes of venous thrombosis (7.7%; 1 superficial, 1 deep) (Table 4). There were no documented infections. Six reoperations (23.1%) were performed for the 6 component failures (2 traumatic dislocations of prosthesis resulting in acute glenoid component failure, 3 cases of atraumatic glenoid loosening, 1 case of humeral stem loosening after periprosthetic fracture). Atraumatic glenoid component loosening occurred a mean (SD) of 40.6 (14.2) months after surgery (range, 20.8-54.2 months).
Surgical Failures
Eight service members underwent MEB. Six patients experienced component failure. Factors contributing to both clinical failure and separation from active duty by means of MEB were evaluated with univariate analysis (Table 5). No statistically significant risk factors, including surgical revision and presence of perioperative complications, were identified.
Discussion
We confirmed that our cohort of young service members (mean age, 45.8 years), who had undergone TSA for glenohumeral arthritis, had a relatively higher rate of component failure (23.1%) and a higher reoperation rate (23.1%) with low rates of return to military duty at short-term to midterm follow-up. Our results parallel those of a limited series with a younger cohort (Table 6).7,16,19,21,23,24 The high demand and increased life expectancy of the younger patients with glenohumeral arthritis potentiates the risk of complications, component loosening, and ultimate failure.29 To our knowledge, the present article is the first to report clinical and functional outcomes and perioperative risk profiles in a homogenously young, active military cohort after TSA.
The mean age of our study population (46 years) is one of the lowest in the literature. TSA in younger patients (age, <50-55 years) and older, active patients (>55 years) has received increased attention as a result of the expanding indications and growing popularity of TSA in these groups. Other studies have upheld the efficacy of TSA in achieving predictable pain relief and functional improvement in a diverse and predominantly elderly population.15,30-34 Alternative treatments, including humeral head resurfacing15,30,35 and soft-tissue interposition,15,36-40 have also shown inferior short- and long-term results in terms of longevity and degree of clinical or functional improvement.31-34,41 In addition, the ream-and-run technique has had promising early results by improving glenohumeral kinematics, pain relief, and shoulder function.13,42,43 However, although implantation of a glenoid component is avoided in young, active people because of reduced longevity and higher rates of component failure, the trade-offs are inadequately treated glenoid disease, suboptimal pain relief, and progression of glenoid arthritis eventually requiring revision. Furthermore, midterm and long-term survivorship of TSA in general is unknown, and there remain few good options for treating end-stage arthritis in young, active patients.
Our cohort had high rates of complications (46.2%) and revisions (23.1%). Two in 5 patients had postoperative complications, most commonly component failure resulting in reoperation. In the literature, complication rates among young patients who underwent TSA are much lower (4.8%-10.9%).16,23,24 Our cohort’s most common complication was component failure (23.1%), which was most often attributed to atraumatic, aseptic glenoid component loosening and required reoperation. Previously reported revision rates in a young population that underwent TSA (0%-11%)16,23,24 were also significantly lower than those in the present analysis (23.1%), underscoring the impact of operative indications, postoperative activity levels, and occupational demands on ultimate failure rates. Interestingly, all revisions in our study were for component failure, whereas previous reports have described a higher rate for infection.22 However, the same studies also found glenoid lucency rates as high as 76% at 10-year follow-up.16 Furthermore, in a review of 136 TSAs with unsatisfactory outcomes, glenoid loosening was the most common reason for presenting to clinic after surgery.44 Specifically, our population had a high rate of glenohumeral arthritis secondary to instability (50.0%) and posttraumatic osteoarthritis (26.9%). For many reasons, outcomes were worse in younger patients with a history of glenohumeral instability33 than in older patients without a high incidence of instability.45 This young cohort with higher demands may have had accelerated polyethylene wear patterns caused by repetitive overhead activity, which may have arisen because of a higher functional profile after surgery and greater patient expectations after arthroplasty. In addition, patients with a history of instability may have altered glenohumeral anatomy, especially with previous arthroscopic or open stabilization procedures. Anatomical changes include excessive posterior glenoid wear, internal rotation contracture, patulous capsular tissue, static or dynamic posterior humeral subluxation, and possible overconstraint after prior stabilization procedures. Almost half of our population had a previous surgery; our patients averaged 1.7 previous surgeries each.
Although estimates of component survivorship at a high-volume civilian tertiary-referral center were as high as 97% at 10 years and 84% at 20 years,7,16 10-year survivorship in patients with a history of instability was only 61%.3 TSA survivorship in our young, active cohort is already foreseeably dramatically reduced, given the 23.1% revision rate at 28.5-month follow-up. This consideration must be addressed during preoperative counseling with the young patient with glenohumeral arthritis and a history of shoulder instability.
Despite the high rates of complications and revisions in our study, 92.3% of patients were satisfied with surgery, 88.0% experienced minimal persistence of pain (mean 3.8-point decrease on SRPS), and 100% maintained improved ROM at final follow-up. Satisfaction in the young population has varied significantly, from 52% to 95%, generally on the basis of physical activity.16,22-24 The reasonable rate of postoperative satisfaction in the present analysis is comparable to what has been reported in patients of a similar age (Table 6).7,16,22 However, despite high satisfaction and pain relief, patients were inconsistently able to return to the upper limits of physical activity required of active-duty military service. In addition, we cannot exclude secondary gain motivations for pursuing medical retirement, similar to that seen in patients receiving worker’s compensation.
Other authors have conversely found more favorable functional outcomes and survivorship rates.23,24 In a retrospective review of 46 TSAs in patients 55 years or younger, Bartelt and colleagues24 found sustained improvements in pain, ROM, and satisfaction at 7-year follow-up.24 Raiss and colleagues23 conducted a prospective study of TSA outcomes in 21 patients with a mean age of 55 years and a mean follow-up of 7 years and reported no revisions and only 1 minor complication, a transient brachial plexus palsy.23 The discrepancy between these studies may reflect different activity levels and underlying pathology between cohorts. The present population is unique in that it represents a particularly difficult confluence of factors for shoulder arthroplasty surgeons. The high activity, significant overhead and lifting occupational demands, and discordant patient expectations of this military cohort place a significant functional burden on the implants, the glenoid component in particular. Furthermore, this patient group has a higher incidence of more complex glenohumeral pathology resulting in instability, posttraumatic, or capsulorrhaphy arthropathy, and multiple prior arthroscopic and open stabilization procedures.
At final follow-up, only 33% of our patients were still on activity duty, 37.5% had completed or were completing medical separation from the military after surgery for persistent shoulder disability, and 37.5% were retired from the military. Five patients (20.8%) deployed after surgery. This young, active cohort of service members who had TSA for glenohumeral arthritis faced a unique set of tremendous physical demands. A retrospective case series investigated return to sport in 100 consecutive patients (mean age, 68.9 years) who were participating in recreational and competitive athletics and underwent unilateral TSA.21 The patients were engaged most commonly in swimming (20.4%), golf (16.3%), cycling (16.3%), and fitness training (16.3%). The authors found that, at a mean follow-up of 2.8 years, 49 patients (89%) were able to continue in sports, though 36.7% thought their sport activity was restricted after TSA. In another retrospective case series (61 TSAs), McCarty and colleagues19 found that 48 patients (71%) were improved in their sports participation, and 50% increased their frequency of participation after surgery.
There are no specific recommendations on returning to military service or high-level sport after surgery. Recommendations on returning to sport after TSA have been based largely on small case series involving specific sports46,47 and surveys of expert opinion.17,18 In a survey on postoperative physical activity in young patients after TSA conducted by Healy and colleagues,17 35 American Shoulder and Elbow Surgeons members recommended avoiding contact and impact sports while permitting return to nonimpact sports, such as swimming, which may still impart significant stress to the glenohumeral joint. In an international survey of 101 shoulder and elbow surgeons, Magnussen and colleagues18 also found that most recommended avoiding a return to impact sports that require intensive upper extremity demands and permitting full return to sports at preoperative levels. This likely is a result of the perception that most of these patients having TSA are older and have less rigorous involvement in sports at the outset and a lower propensity for adverse patient outcomes. However, these recommendations may place a younger, more high-demand patient at significantly greater risk. The active-duty cohort engages in daily physical training, including push-ups and frequent overhead lifting, which could account for the high failure rates and low incidence of postoperative deployment. Although TSA seems to demonstrate good initial results in terms of return to high-demand activities, the return-to-duty profile in our study highlights the potential pitfalls of TSA in active individuals attempting to return to high-demand preoperative function.
Our analysis was limited by the fact that we used a small patient cohort, contributing to underpowered analysis of the potential risk factors predictive of reoperation and medical discharge. Although our minimum follow-up was 12 months, with the exception of 1 patient who was medically separated at 11.6 months because of shoulder disability, we captured 5 patients (19.2%) who underwent medical separation but who would otherwise be excluded. Therefore, this limitation is not major in that, with a longer minimum follow-up, we would be excluding a significant number of patients with such persistent disability after TSA that they would not be able to return to duty at anywhere near their previous level. In this retrospective study, we were additionally limited to analysis of the data in the medical records and could not control for variables such as surgeon technique, implant choice, and experience. Complete radiographic images were not available, limiting analysis of radiographic outcomes. Given the lack of a standardized preoperative imaging protocol, we could not evaluate glenoid version on axial imaging. It is possible that some patients with early aseptic glenoid loosening had posterior subluxation or a Walch B2 glenoid, which has a higher failure rate.48 The strengths of this study include its unique analysis of a homogeneous young, active, high-risk patient cohort within a closed healthcare system. In the military, these patients are subject to intense daily physical and occupational demands. In addition, the clinical and functional outcomes we studied are patient-centered and therefore relevant during preoperative counseling. Further investigations might focus on validated outcome measures and on midterm to long-term TSA outcomes in an active military population vis-à-vis other alternatives for clinical management.
Conclusion
By a mean follow-up of 3.5 years, only a third of the service members had returned to active duty, roughly a third had retired, and more than a third had been medically discharged because of persistent disability attributable to the shoulder. Despite initial improvements in ROM and pain, midterm outcomes were poor. The short-term complication rate (46.2%) and the rate of reoperation for component failure (23.1%) should be emphasized during preoperative counseling.
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8. Denard PJ, Wirth MA, Orfaly RM. Management of glenohumeral arthritis in the young adult. J Bone Joint Surg Am. 2011;93(9):885-892.
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10 Millett PJ, Gaskill TR. Arthroscopic management of glenohumeral arthrosis: humeral osteoplasty, capsular release, and arthroscopic axillary nerve release as a joint-preserving approach. Arthroscopy. 2011;27(9):1296-1303.
11. Savoie FH 3rd, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: midterm results. Arthroscopy. 2009;25(8):864-871.
12. Strauss EJ, Verma NN, Salata MJ, et al. The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2014;23(3):409-419.
13. Matsen FA 3rd, Warme WJ, Jackins SE. Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad? Clin Orthop Relat Res. 2015;473(6):2088-2096.
14. Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87(10):2178-2185.
15. Wirth M, Tapscott RS, Southworth C, Rockwood CA Jr. Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study. J Bone Joint Surg Am. 2006;88(5):964-973.
16. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004;13(6):604-613.
17. Healy WL, Iorio R, Lemos MJ. Athletic activity after joint replacement. Am J Sports Med. 2001;29(3):377-388.
18. Magnussen RA, Mallon WJ, Willems WJ, Moorman CT 3rd. Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons. J Shoulder Elbow Surg. 2011;20(2):281-289.
19. McCarty EC, Marx RG, Maerz D, Altchek D, Warren RF. Sports participation after shoulder replacement surgery. Am J Sports Med. 2008;36(8):1577-1581.
20. Schmidt-Wiethoff R, Wolf P, Lehmann M, Habermeyer P. Physical activity after shoulder arthroplasty [in German]. Sportverletz Sportschaden. 2002;16(1):26-30.
21. Schumann K, Flury MP, Schwyzer HK, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med. 2010;38(10):2097-2105.
22. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am. 1998;80(4):464-473.
23. Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis. J Bone Joint Surg Br. 2008;90(6):764-769.
24. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011;20(1):123-130.
25. Waterman BR, Burns TC, McCriskin B, Kilcoyne K, Cameron KL, Owens BD. Outcomes after Bankart repair in a military population: predictors for surgical revision and long-term disability. Arthroscopy. 2014;30(2):172-177.
26. Waterman BR, Liu J, Newcomb R, Schoenfeld AJ, Orr JD, Belmont PJ Jr. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med. 2013;41(11):2545-2549.
27. Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860.
28. Dunn JC, Lanzi J, Kusnezov N, Bader J, Waterman BR, Belmont PJ Jr. Predictors of length of stay after elective total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(5):754-759.
29. Hayes PR, Flatow EL. Total shoulder arthroplasty in the young patient. Instr Course Lect. 2001;50;73-88.
30. Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Humeral head replacement for the treatment of osteoarthritis. J Bone Joint Surg Am. 2006;88(12):2637-2644.
31. Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007;16(4):396-402.
32. Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am. 2000;82(1):26-34.
33. Edwards TB, Kadakia NR, Boulahia A, et al. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg. 2003;12(3):
207-213.
34. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(9):1947-1956.
35. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. J Bone Joint Surg Am. 2008;90(1):110-117.
36. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft interposition arthroplasty for the arthritic shoulder: description of a new surgical technique. Tech Shoulder Elbow Surg. 2001;2:247-254.
37. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am. 2009;91(2):419-424.
38. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes. J Bone Joint Surg Am. 2007;89(4):727-734.
39. Lee KT, Bell S, Salmon J. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. J Shoulder Elbow Surg. 2009;18(6):915-919.
40. Nicholson GP, Goldstein JL, Romeo AA, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. J Shoulder Elbow Surg. 2007;16(5 suppl):S261-S266.
41. Carroll RM, Izquierdo R, Vazquez M, Blaine TA, Levine WN, Bigliani LU. Conversion of painful hemiarthroplasty to total shoulder arthroplasty: long-term results. J Shoulder Elbow Surg. 2004;13(6):599-603.
42. Clinton J, Franta AK, Lenters TR, Mounce D, Matsen FA 3rd. Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16(5):534-538.
43. Gilmer BB, Comstock BA, Jette JL, Warme WJ, Jackins SE, Matsen FA. The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases. J Bone Joint Surg Am. 2012;94(14):e102.
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45. Godenèche A, Boileau P, Favard L, et al. Prosthetic replacement in the treatment of osteoarthritis of the shoulder: early results of 268 cases. J Shoulder Elbow Surg. 2002;11(1):11-18.
46. Jensen KL, Rockwood CA Jr. Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg. 1998;7(4):362-367.
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48. Raiss P, Edwards TB, Deutsch A, et al. Radiographic changes around humeral components in shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(7):e54.
Although total shoulder arthroplasty (TSA) has proved to be a reliable solution in older patients, treatment in younger patients with glenohumeral arthritis remains controversial, and there are still few reliable long-term surgical options.1-8 These options include abrasion arthroplasty and arthroscopic management,9,10 biologic glenoid resurfacing,11,12 and humeral hemiarthroplasty with13 or without14,15 glenoid treatment and anatomical TSA.
In the younger cohort, 20-year TSA survivorship rates up to 84% have been reported, and unsatisfactory subjective outcomes have been unacceptably high.16 In addition, there is a paucity of literature addressing the impact of TSA on return to sport. Recommendations on returning to an athletic life style are based largely on surveys of expert opinion17,18 and heterogeneous studies of either older patients (eg, age >50-55 years) who are active19-21 or younger patients with no defined level of activity.5,7,8,16,22-24
To our knowledge, no one has evaluated the short-term morbidity and clinical outcomes within a young, high-demand patient population, such as the US military. Therefore, we conducted a study to evaluate the clinical success and complications of TSA performed for glenohumeral arthritis in a young, active population. We hypothesized that patients who had undergone TSA would have a low rate of return to duty, an increased rate of component failure, and a higher reoperation rate because of increased upper extremity demands.
Materials and Methods
After obtaining protocol approval from the William Beaumont Army Medical Center Institutional Review Board, we searched the Military Health System (MHS) Management Analysis and Reporting Tool (M2) database to retrospectively review the cases of all tri-service US military service members who had undergone primary anatomical TSA (Current Procedural Terminology code 23472) between January 1, 2007 and June 31, 2014. This was a multisurgeon, multicenter study. Patient exclusion criteria were nonmilitary or retired status at time of surgery; primary surgery consisting of limited glenohumeral resurfacing procedure, hemiarthroplasty, or reverse TSA; surgery for acute proximal humerus fracture; rotator cuff deficiency diagnosed before or during surgery; and insufficient follow-up (eg, <12 months, unless medically separated beforehand).
The M2 database is an established tool that has been used for clinical outcomes research on treatment of a variety of orthopedic conditions.25,26 The Medical Data Repository, which is operated by MHS, is populated by its military healthcare providers. The MHS, which offers worldwide coverage for all beneficiaries either at Department of Defense facilities or purchased using civilian providers, is among the largest known closed healthcare systems.
All active-duty US military service members are uniformly required to adhere to stringent and regularly evaluated physical fitness standards, which typically exceed those of average civilians. Routine physical training is required in the form of aerobic fitness, weight training, tactical field exercises, and core military tasks, such as the ability to march at least 2 miles while carrying heavy fighting loads. In addition to satisfying required height and weight standards, all service members are subject to semiannual service-specific physical fitness evaluations inclusive of timed push-ups, sit-ups, and an aerobic event. Service members may also be required to maintain a level of physical training above these baseline standards, contingent on their branch of service, rank, and military occupational specialty. If a service member is unable to maintain these standards, medical separation may be initiated.
Demographic and occupational data were extracted from the database. These data included age, sex, military rank, and branch of service. Line-by-line analysis of the Armed Forces Health Longitudinal Technology Application (Version 22; 3M) electronic medical record was then performed to confirm the underlying diagnosis, surgical procedure, and surgery date. Further chart review yielded additional patient-based factors (eg, laterality, hand dominance, presence and type of prior shoulder surgeries) and surgical factors (eg, surgery indication, implant design). We evaluated clinical and functional outcomes as well as perioperative complications, including both major and minor systemic and local complications as previously described27,28; preoperative and postoperative range of motion (ROM) and self-reported pain score (SRPS, scale 1-10) as measured by physical therapist and surgeon at follow-up; secondary surgical interventions; timing of return to duty; and postoperative deployment history. The primary outcome measures were revision reoperation after index procedure, and military discharge for persistent shoulder-related disability. Clinical failure was defined as component failure or reoperation. Medical Evaluation Board (MEB) is a formal separation from the military in which it is deemed that a service member is no longer able to fulfill his or her duty because of a medical condition.
Statistical Analysis
Continuous variables were compared using statistical means with 95% confidence intervals (CIs) and/or SDs. Categorical data were reported as frequencies or percentages. Univariate analysis was performed to assess the correlation between possible risk factors and the primary outcome measures. P < .05 was considered statistically significant.
Results
Demographics
We identified 24 service members (26 shoulders) who had undergone anatomical TSA during the study period (Table 1). Mean (SD) age was 45.8 (4.5) years (range, 35-54 years), and the cohort was predominately male (25/26 shoulders; 96.2%). Most cohort members were of senior enlisted rank (14, 58.3%), and the US Army was the predominant branch of military service (13, 54.2%). The right side was the operative extremity in 7 cases (26.9%), and the dominant shoulder was involved in 6 cases (23.1%). Two patients (8.3%) underwent staged bilateral TSA. Most patients (76.9%) underwent TSA on the nondominant extremity.
Surgical Variables
TSA was indicated for post-instability arthropathy in 13 cases (50.0%), posttraumatic osteoarthritis in 7 cases (26.9%), and unspecified glenohumeral arthritis, which includes primary glenohumeral osteoarthritis, in 5 cases (19.2%) (Table 2). One case was attributed to iatrogenically induced chondrolysis secondary to intra-articular lidocaine pump. Twelve patients (46.2%) had at least 1 previous surgery. Of the shoulders with instability, 10 (76.9%) had undergone a total of 14 surgical stabilization procedures—10 anterior labral repairs, 2 posterior labral repairs, and 2 capsular plications. The other shoulders had undergone a total of 18 procedures, which included 4 rotator cuff repairs and 3 cartilage restoration procedures.
Clinical Outcomes
Mean (SD) follow-up was 41.0 (21.3) months (range, 11.6-97.6 months). All but 1 shoulder (96.2%) had follow-up of 12 months or more (the only patient with shorter follow-up was because of MEB), and 76.9% of patients had follow-up of 24 months or more (4 of the 6 patients with follow-up under 24 months were medically separated) (Table 3). In all cases, mean ROM improved with respect to flexion, abduction, and external rotation. At final follow-up, mean (SD) ROM was 138° (36°) forward flexion (range, 60°-180°), 125° (39°) abduction (range, 45°-180°), 48° (19°) external rotation at 0° abduction (range, 20°-90°), and 80° (9.4°) external rotation at 90° abduction (range, 70°-90°). Preoperative flexion, abduction, and external rotation at 0° and 90° abduction were all improved at final follow-up. The most improvement in ROM occurred within 6 months after surgery.
Overall patient satisfaction with surgery was 92.3% (n = 24). Ultimately, 18 (72.0%) of 25 shoulders with follow-up of 1 year or more were able to return to active duty within 1 year after surgery, though only 10 (45.5%) of 22 with follow-up of 2 years or more remained active 2 years after surgery. Furthermore, 5 patients (20.8%) were deployed after surgery, and all were still on active duty at final follow-up. By final follow-up, 9 (37.5%) of 24 service members were unable to return to military function; 7 had been medically discharged from the military for persistent shoulder disability, and 2 were in the process of being medically discharged.
In all cases, SRPS improved from before surgery (5.2 out of 10) to final follow-up (1.4). At final follow-up, 22 patients (88.0%) reported mild pain (0-3), and no one had pain above 6.
Complications
Nine patients had a total of 12 postoperative complications (46.2%): 6 component failures (23.1%), 2 neurologic injuries (7.7%; 1 permanent axillary nerve injury, 1 transient brachial plexus neuritis), 2 cases of adhesive capsulitis (7.7%), and 2 episodes of venous thrombosis (7.7%; 1 superficial, 1 deep) (Table 4). There were no documented infections. Six reoperations (23.1%) were performed for the 6 component failures (2 traumatic dislocations of prosthesis resulting in acute glenoid component failure, 3 cases of atraumatic glenoid loosening, 1 case of humeral stem loosening after periprosthetic fracture). Atraumatic glenoid component loosening occurred a mean (SD) of 40.6 (14.2) months after surgery (range, 20.8-54.2 months).
Surgical Failures
Eight service members underwent MEB. Six patients experienced component failure. Factors contributing to both clinical failure and separation from active duty by means of MEB were evaluated with univariate analysis (Table 5). No statistically significant risk factors, including surgical revision and presence of perioperative complications, were identified.
Discussion
We confirmed that our cohort of young service members (mean age, 45.8 years), who had undergone TSA for glenohumeral arthritis, had a relatively higher rate of component failure (23.1%) and a higher reoperation rate (23.1%) with low rates of return to military duty at short-term to midterm follow-up. Our results parallel those of a limited series with a younger cohort (Table 6).7,16,19,21,23,24 The high demand and increased life expectancy of the younger patients with glenohumeral arthritis potentiates the risk of complications, component loosening, and ultimate failure.29 To our knowledge, the present article is the first to report clinical and functional outcomes and perioperative risk profiles in a homogenously young, active military cohort after TSA.
The mean age of our study population (46 years) is one of the lowest in the literature. TSA in younger patients (age, <50-55 years) and older, active patients (>55 years) has received increased attention as a result of the expanding indications and growing popularity of TSA in these groups. Other studies have upheld the efficacy of TSA in achieving predictable pain relief and functional improvement in a diverse and predominantly elderly population.15,30-34 Alternative treatments, including humeral head resurfacing15,30,35 and soft-tissue interposition,15,36-40 have also shown inferior short- and long-term results in terms of longevity and degree of clinical or functional improvement.31-34,41 In addition, the ream-and-run technique has had promising early results by improving glenohumeral kinematics, pain relief, and shoulder function.13,42,43 However, although implantation of a glenoid component is avoided in young, active people because of reduced longevity and higher rates of component failure, the trade-offs are inadequately treated glenoid disease, suboptimal pain relief, and progression of glenoid arthritis eventually requiring revision. Furthermore, midterm and long-term survivorship of TSA in general is unknown, and there remain few good options for treating end-stage arthritis in young, active patients.
Our cohort had high rates of complications (46.2%) and revisions (23.1%). Two in 5 patients had postoperative complications, most commonly component failure resulting in reoperation. In the literature, complication rates among young patients who underwent TSA are much lower (4.8%-10.9%).16,23,24 Our cohort’s most common complication was component failure (23.1%), which was most often attributed to atraumatic, aseptic glenoid component loosening and required reoperation. Previously reported revision rates in a young population that underwent TSA (0%-11%)16,23,24 were also significantly lower than those in the present analysis (23.1%), underscoring the impact of operative indications, postoperative activity levels, and occupational demands on ultimate failure rates. Interestingly, all revisions in our study were for component failure, whereas previous reports have described a higher rate for infection.22 However, the same studies also found glenoid lucency rates as high as 76% at 10-year follow-up.16 Furthermore, in a review of 136 TSAs with unsatisfactory outcomes, glenoid loosening was the most common reason for presenting to clinic after surgery.44 Specifically, our population had a high rate of glenohumeral arthritis secondary to instability (50.0%) and posttraumatic osteoarthritis (26.9%). For many reasons, outcomes were worse in younger patients with a history of glenohumeral instability33 than in older patients without a high incidence of instability.45 This young cohort with higher demands may have had accelerated polyethylene wear patterns caused by repetitive overhead activity, which may have arisen because of a higher functional profile after surgery and greater patient expectations after arthroplasty. In addition, patients with a history of instability may have altered glenohumeral anatomy, especially with previous arthroscopic or open stabilization procedures. Anatomical changes include excessive posterior glenoid wear, internal rotation contracture, patulous capsular tissue, static or dynamic posterior humeral subluxation, and possible overconstraint after prior stabilization procedures. Almost half of our population had a previous surgery; our patients averaged 1.7 previous surgeries each.
Although estimates of component survivorship at a high-volume civilian tertiary-referral center were as high as 97% at 10 years and 84% at 20 years,7,16 10-year survivorship in patients with a history of instability was only 61%.3 TSA survivorship in our young, active cohort is already foreseeably dramatically reduced, given the 23.1% revision rate at 28.5-month follow-up. This consideration must be addressed during preoperative counseling with the young patient with glenohumeral arthritis and a history of shoulder instability.
Despite the high rates of complications and revisions in our study, 92.3% of patients were satisfied with surgery, 88.0% experienced minimal persistence of pain (mean 3.8-point decrease on SRPS), and 100% maintained improved ROM at final follow-up. Satisfaction in the young population has varied significantly, from 52% to 95%, generally on the basis of physical activity.16,22-24 The reasonable rate of postoperative satisfaction in the present analysis is comparable to what has been reported in patients of a similar age (Table 6).7,16,22 However, despite high satisfaction and pain relief, patients were inconsistently able to return to the upper limits of physical activity required of active-duty military service. In addition, we cannot exclude secondary gain motivations for pursuing medical retirement, similar to that seen in patients receiving worker’s compensation.
Other authors have conversely found more favorable functional outcomes and survivorship rates.23,24 In a retrospective review of 46 TSAs in patients 55 years or younger, Bartelt and colleagues24 found sustained improvements in pain, ROM, and satisfaction at 7-year follow-up.24 Raiss and colleagues23 conducted a prospective study of TSA outcomes in 21 patients with a mean age of 55 years and a mean follow-up of 7 years and reported no revisions and only 1 minor complication, a transient brachial plexus palsy.23 The discrepancy between these studies may reflect different activity levels and underlying pathology between cohorts. The present population is unique in that it represents a particularly difficult confluence of factors for shoulder arthroplasty surgeons. The high activity, significant overhead and lifting occupational demands, and discordant patient expectations of this military cohort place a significant functional burden on the implants, the glenoid component in particular. Furthermore, this patient group has a higher incidence of more complex glenohumeral pathology resulting in instability, posttraumatic, or capsulorrhaphy arthropathy, and multiple prior arthroscopic and open stabilization procedures.
At final follow-up, only 33% of our patients were still on activity duty, 37.5% had completed or were completing medical separation from the military after surgery for persistent shoulder disability, and 37.5% were retired from the military. Five patients (20.8%) deployed after surgery. This young, active cohort of service members who had TSA for glenohumeral arthritis faced a unique set of tremendous physical demands. A retrospective case series investigated return to sport in 100 consecutive patients (mean age, 68.9 years) who were participating in recreational and competitive athletics and underwent unilateral TSA.21 The patients were engaged most commonly in swimming (20.4%), golf (16.3%), cycling (16.3%), and fitness training (16.3%). The authors found that, at a mean follow-up of 2.8 years, 49 patients (89%) were able to continue in sports, though 36.7% thought their sport activity was restricted after TSA. In another retrospective case series (61 TSAs), McCarty and colleagues19 found that 48 patients (71%) were improved in their sports participation, and 50% increased their frequency of participation after surgery.
There are no specific recommendations on returning to military service or high-level sport after surgery. Recommendations on returning to sport after TSA have been based largely on small case series involving specific sports46,47 and surveys of expert opinion.17,18 In a survey on postoperative physical activity in young patients after TSA conducted by Healy and colleagues,17 35 American Shoulder and Elbow Surgeons members recommended avoiding contact and impact sports while permitting return to nonimpact sports, such as swimming, which may still impart significant stress to the glenohumeral joint. In an international survey of 101 shoulder and elbow surgeons, Magnussen and colleagues18 also found that most recommended avoiding a return to impact sports that require intensive upper extremity demands and permitting full return to sports at preoperative levels. This likely is a result of the perception that most of these patients having TSA are older and have less rigorous involvement in sports at the outset and a lower propensity for adverse patient outcomes. However, these recommendations may place a younger, more high-demand patient at significantly greater risk. The active-duty cohort engages in daily physical training, including push-ups and frequent overhead lifting, which could account for the high failure rates and low incidence of postoperative deployment. Although TSA seems to demonstrate good initial results in terms of return to high-demand activities, the return-to-duty profile in our study highlights the potential pitfalls of TSA in active individuals attempting to return to high-demand preoperative function.
Our analysis was limited by the fact that we used a small patient cohort, contributing to underpowered analysis of the potential risk factors predictive of reoperation and medical discharge. Although our minimum follow-up was 12 months, with the exception of 1 patient who was medically separated at 11.6 months because of shoulder disability, we captured 5 patients (19.2%) who underwent medical separation but who would otherwise be excluded. Therefore, this limitation is not major in that, with a longer minimum follow-up, we would be excluding a significant number of patients with such persistent disability after TSA that they would not be able to return to duty at anywhere near their previous level. In this retrospective study, we were additionally limited to analysis of the data in the medical records and could not control for variables such as surgeon technique, implant choice, and experience. Complete radiographic images were not available, limiting analysis of radiographic outcomes. Given the lack of a standardized preoperative imaging protocol, we could not evaluate glenoid version on axial imaging. It is possible that some patients with early aseptic glenoid loosening had posterior subluxation or a Walch B2 glenoid, which has a higher failure rate.48 The strengths of this study include its unique analysis of a homogeneous young, active, high-risk patient cohort within a closed healthcare system. In the military, these patients are subject to intense daily physical and occupational demands. In addition, the clinical and functional outcomes we studied are patient-centered and therefore relevant during preoperative counseling. Further investigations might focus on validated outcome measures and on midterm to long-term TSA outcomes in an active military population vis-à-vis other alternatives for clinical management.
Conclusion
By a mean follow-up of 3.5 years, only a third of the service members had returned to active duty, roughly a third had retired, and more than a third had been medically discharged because of persistent disability attributable to the shoulder. Despite initial improvements in ROM and pain, midterm outcomes were poor. The short-term complication rate (46.2%) and the rate of reoperation for component failure (23.1%) should be emphasized during preoperative counseling.
Although total shoulder arthroplasty (TSA) has proved to be a reliable solution in older patients, treatment in younger patients with glenohumeral arthritis remains controversial, and there are still few reliable long-term surgical options.1-8 These options include abrasion arthroplasty and arthroscopic management,9,10 biologic glenoid resurfacing,11,12 and humeral hemiarthroplasty with13 or without14,15 glenoid treatment and anatomical TSA.
In the younger cohort, 20-year TSA survivorship rates up to 84% have been reported, and unsatisfactory subjective outcomes have been unacceptably high.16 In addition, there is a paucity of literature addressing the impact of TSA on return to sport. Recommendations on returning to an athletic life style are based largely on surveys of expert opinion17,18 and heterogeneous studies of either older patients (eg, age >50-55 years) who are active19-21 or younger patients with no defined level of activity.5,7,8,16,22-24
To our knowledge, no one has evaluated the short-term morbidity and clinical outcomes within a young, high-demand patient population, such as the US military. Therefore, we conducted a study to evaluate the clinical success and complications of TSA performed for glenohumeral arthritis in a young, active population. We hypothesized that patients who had undergone TSA would have a low rate of return to duty, an increased rate of component failure, and a higher reoperation rate because of increased upper extremity demands.
Materials and Methods
After obtaining protocol approval from the William Beaumont Army Medical Center Institutional Review Board, we searched the Military Health System (MHS) Management Analysis and Reporting Tool (M2) database to retrospectively review the cases of all tri-service US military service members who had undergone primary anatomical TSA (Current Procedural Terminology code 23472) between January 1, 2007 and June 31, 2014. This was a multisurgeon, multicenter study. Patient exclusion criteria were nonmilitary or retired status at time of surgery; primary surgery consisting of limited glenohumeral resurfacing procedure, hemiarthroplasty, or reverse TSA; surgery for acute proximal humerus fracture; rotator cuff deficiency diagnosed before or during surgery; and insufficient follow-up (eg, <12 months, unless medically separated beforehand).
The M2 database is an established tool that has been used for clinical outcomes research on treatment of a variety of orthopedic conditions.25,26 The Medical Data Repository, which is operated by MHS, is populated by its military healthcare providers. The MHS, which offers worldwide coverage for all beneficiaries either at Department of Defense facilities or purchased using civilian providers, is among the largest known closed healthcare systems.
All active-duty US military service members are uniformly required to adhere to stringent and regularly evaluated physical fitness standards, which typically exceed those of average civilians. Routine physical training is required in the form of aerobic fitness, weight training, tactical field exercises, and core military tasks, such as the ability to march at least 2 miles while carrying heavy fighting loads. In addition to satisfying required height and weight standards, all service members are subject to semiannual service-specific physical fitness evaluations inclusive of timed push-ups, sit-ups, and an aerobic event. Service members may also be required to maintain a level of physical training above these baseline standards, contingent on their branch of service, rank, and military occupational specialty. If a service member is unable to maintain these standards, medical separation may be initiated.
Demographic and occupational data were extracted from the database. These data included age, sex, military rank, and branch of service. Line-by-line analysis of the Armed Forces Health Longitudinal Technology Application (Version 22; 3M) electronic medical record was then performed to confirm the underlying diagnosis, surgical procedure, and surgery date. Further chart review yielded additional patient-based factors (eg, laterality, hand dominance, presence and type of prior shoulder surgeries) and surgical factors (eg, surgery indication, implant design). We evaluated clinical and functional outcomes as well as perioperative complications, including both major and minor systemic and local complications as previously described27,28; preoperative and postoperative range of motion (ROM) and self-reported pain score (SRPS, scale 1-10) as measured by physical therapist and surgeon at follow-up; secondary surgical interventions; timing of return to duty; and postoperative deployment history. The primary outcome measures were revision reoperation after index procedure, and military discharge for persistent shoulder-related disability. Clinical failure was defined as component failure or reoperation. Medical Evaluation Board (MEB) is a formal separation from the military in which it is deemed that a service member is no longer able to fulfill his or her duty because of a medical condition.
Statistical Analysis
Continuous variables were compared using statistical means with 95% confidence intervals (CIs) and/or SDs. Categorical data were reported as frequencies or percentages. Univariate analysis was performed to assess the correlation between possible risk factors and the primary outcome measures. P < .05 was considered statistically significant.
Results
Demographics
We identified 24 service members (26 shoulders) who had undergone anatomical TSA during the study period (Table 1). Mean (SD) age was 45.8 (4.5) years (range, 35-54 years), and the cohort was predominately male (25/26 shoulders; 96.2%). Most cohort members were of senior enlisted rank (14, 58.3%), and the US Army was the predominant branch of military service (13, 54.2%). The right side was the operative extremity in 7 cases (26.9%), and the dominant shoulder was involved in 6 cases (23.1%). Two patients (8.3%) underwent staged bilateral TSA. Most patients (76.9%) underwent TSA on the nondominant extremity.
Surgical Variables
TSA was indicated for post-instability arthropathy in 13 cases (50.0%), posttraumatic osteoarthritis in 7 cases (26.9%), and unspecified glenohumeral arthritis, which includes primary glenohumeral osteoarthritis, in 5 cases (19.2%) (Table 2). One case was attributed to iatrogenically induced chondrolysis secondary to intra-articular lidocaine pump. Twelve patients (46.2%) had at least 1 previous surgery. Of the shoulders with instability, 10 (76.9%) had undergone a total of 14 surgical stabilization procedures—10 anterior labral repairs, 2 posterior labral repairs, and 2 capsular plications. The other shoulders had undergone a total of 18 procedures, which included 4 rotator cuff repairs and 3 cartilage restoration procedures.
Clinical Outcomes
Mean (SD) follow-up was 41.0 (21.3) months (range, 11.6-97.6 months). All but 1 shoulder (96.2%) had follow-up of 12 months or more (the only patient with shorter follow-up was because of MEB), and 76.9% of patients had follow-up of 24 months or more (4 of the 6 patients with follow-up under 24 months were medically separated) (Table 3). In all cases, mean ROM improved with respect to flexion, abduction, and external rotation. At final follow-up, mean (SD) ROM was 138° (36°) forward flexion (range, 60°-180°), 125° (39°) abduction (range, 45°-180°), 48° (19°) external rotation at 0° abduction (range, 20°-90°), and 80° (9.4°) external rotation at 90° abduction (range, 70°-90°). Preoperative flexion, abduction, and external rotation at 0° and 90° abduction were all improved at final follow-up. The most improvement in ROM occurred within 6 months after surgery.
Overall patient satisfaction with surgery was 92.3% (n = 24). Ultimately, 18 (72.0%) of 25 shoulders with follow-up of 1 year or more were able to return to active duty within 1 year after surgery, though only 10 (45.5%) of 22 with follow-up of 2 years or more remained active 2 years after surgery. Furthermore, 5 patients (20.8%) were deployed after surgery, and all were still on active duty at final follow-up. By final follow-up, 9 (37.5%) of 24 service members were unable to return to military function; 7 had been medically discharged from the military for persistent shoulder disability, and 2 were in the process of being medically discharged.
In all cases, SRPS improved from before surgery (5.2 out of 10) to final follow-up (1.4). At final follow-up, 22 patients (88.0%) reported mild pain (0-3), and no one had pain above 6.
Complications
Nine patients had a total of 12 postoperative complications (46.2%): 6 component failures (23.1%), 2 neurologic injuries (7.7%; 1 permanent axillary nerve injury, 1 transient brachial plexus neuritis), 2 cases of adhesive capsulitis (7.7%), and 2 episodes of venous thrombosis (7.7%; 1 superficial, 1 deep) (Table 4). There were no documented infections. Six reoperations (23.1%) were performed for the 6 component failures (2 traumatic dislocations of prosthesis resulting in acute glenoid component failure, 3 cases of atraumatic glenoid loosening, 1 case of humeral stem loosening after periprosthetic fracture). Atraumatic glenoid component loosening occurred a mean (SD) of 40.6 (14.2) months after surgery (range, 20.8-54.2 months).
Surgical Failures
Eight service members underwent MEB. Six patients experienced component failure. Factors contributing to both clinical failure and separation from active duty by means of MEB were evaluated with univariate analysis (Table 5). No statistically significant risk factors, including surgical revision and presence of perioperative complications, were identified.
Discussion
We confirmed that our cohort of young service members (mean age, 45.8 years), who had undergone TSA for glenohumeral arthritis, had a relatively higher rate of component failure (23.1%) and a higher reoperation rate (23.1%) with low rates of return to military duty at short-term to midterm follow-up. Our results parallel those of a limited series with a younger cohort (Table 6).7,16,19,21,23,24 The high demand and increased life expectancy of the younger patients with glenohumeral arthritis potentiates the risk of complications, component loosening, and ultimate failure.29 To our knowledge, the present article is the first to report clinical and functional outcomes and perioperative risk profiles in a homogenously young, active military cohort after TSA.
The mean age of our study population (46 years) is one of the lowest in the literature. TSA in younger patients (age, <50-55 years) and older, active patients (>55 years) has received increased attention as a result of the expanding indications and growing popularity of TSA in these groups. Other studies have upheld the efficacy of TSA in achieving predictable pain relief and functional improvement in a diverse and predominantly elderly population.15,30-34 Alternative treatments, including humeral head resurfacing15,30,35 and soft-tissue interposition,15,36-40 have also shown inferior short- and long-term results in terms of longevity and degree of clinical or functional improvement.31-34,41 In addition, the ream-and-run technique has had promising early results by improving glenohumeral kinematics, pain relief, and shoulder function.13,42,43 However, although implantation of a glenoid component is avoided in young, active people because of reduced longevity and higher rates of component failure, the trade-offs are inadequately treated glenoid disease, suboptimal pain relief, and progression of glenoid arthritis eventually requiring revision. Furthermore, midterm and long-term survivorship of TSA in general is unknown, and there remain few good options for treating end-stage arthritis in young, active patients.
Our cohort had high rates of complications (46.2%) and revisions (23.1%). Two in 5 patients had postoperative complications, most commonly component failure resulting in reoperation. In the literature, complication rates among young patients who underwent TSA are much lower (4.8%-10.9%).16,23,24 Our cohort’s most common complication was component failure (23.1%), which was most often attributed to atraumatic, aseptic glenoid component loosening and required reoperation. Previously reported revision rates in a young population that underwent TSA (0%-11%)16,23,24 were also significantly lower than those in the present analysis (23.1%), underscoring the impact of operative indications, postoperative activity levels, and occupational demands on ultimate failure rates. Interestingly, all revisions in our study were for component failure, whereas previous reports have described a higher rate for infection.22 However, the same studies also found glenoid lucency rates as high as 76% at 10-year follow-up.16 Furthermore, in a review of 136 TSAs with unsatisfactory outcomes, glenoid loosening was the most common reason for presenting to clinic after surgery.44 Specifically, our population had a high rate of glenohumeral arthritis secondary to instability (50.0%) and posttraumatic osteoarthritis (26.9%). For many reasons, outcomes were worse in younger patients with a history of glenohumeral instability33 than in older patients without a high incidence of instability.45 This young cohort with higher demands may have had accelerated polyethylene wear patterns caused by repetitive overhead activity, which may have arisen because of a higher functional profile after surgery and greater patient expectations after arthroplasty. In addition, patients with a history of instability may have altered glenohumeral anatomy, especially with previous arthroscopic or open stabilization procedures. Anatomical changes include excessive posterior glenoid wear, internal rotation contracture, patulous capsular tissue, static or dynamic posterior humeral subluxation, and possible overconstraint after prior stabilization procedures. Almost half of our population had a previous surgery; our patients averaged 1.7 previous surgeries each.
Although estimates of component survivorship at a high-volume civilian tertiary-referral center were as high as 97% at 10 years and 84% at 20 years,7,16 10-year survivorship in patients with a history of instability was only 61%.3 TSA survivorship in our young, active cohort is already foreseeably dramatically reduced, given the 23.1% revision rate at 28.5-month follow-up. This consideration must be addressed during preoperative counseling with the young patient with glenohumeral arthritis and a history of shoulder instability.
Despite the high rates of complications and revisions in our study, 92.3% of patients were satisfied with surgery, 88.0% experienced minimal persistence of pain (mean 3.8-point decrease on SRPS), and 100% maintained improved ROM at final follow-up. Satisfaction in the young population has varied significantly, from 52% to 95%, generally on the basis of physical activity.16,22-24 The reasonable rate of postoperative satisfaction in the present analysis is comparable to what has been reported in patients of a similar age (Table 6).7,16,22 However, despite high satisfaction and pain relief, patients were inconsistently able to return to the upper limits of physical activity required of active-duty military service. In addition, we cannot exclude secondary gain motivations for pursuing medical retirement, similar to that seen in patients receiving worker’s compensation.
Other authors have conversely found more favorable functional outcomes and survivorship rates.23,24 In a retrospective review of 46 TSAs in patients 55 years or younger, Bartelt and colleagues24 found sustained improvements in pain, ROM, and satisfaction at 7-year follow-up.24 Raiss and colleagues23 conducted a prospective study of TSA outcomes in 21 patients with a mean age of 55 years and a mean follow-up of 7 years and reported no revisions and only 1 minor complication, a transient brachial plexus palsy.23 The discrepancy between these studies may reflect different activity levels and underlying pathology between cohorts. The present population is unique in that it represents a particularly difficult confluence of factors for shoulder arthroplasty surgeons. The high activity, significant overhead and lifting occupational demands, and discordant patient expectations of this military cohort place a significant functional burden on the implants, the glenoid component in particular. Furthermore, this patient group has a higher incidence of more complex glenohumeral pathology resulting in instability, posttraumatic, or capsulorrhaphy arthropathy, and multiple prior arthroscopic and open stabilization procedures.
At final follow-up, only 33% of our patients were still on activity duty, 37.5% had completed or were completing medical separation from the military after surgery for persistent shoulder disability, and 37.5% were retired from the military. Five patients (20.8%) deployed after surgery. This young, active cohort of service members who had TSA for glenohumeral arthritis faced a unique set of tremendous physical demands. A retrospective case series investigated return to sport in 100 consecutive patients (mean age, 68.9 years) who were participating in recreational and competitive athletics and underwent unilateral TSA.21 The patients were engaged most commonly in swimming (20.4%), golf (16.3%), cycling (16.3%), and fitness training (16.3%). The authors found that, at a mean follow-up of 2.8 years, 49 patients (89%) were able to continue in sports, though 36.7% thought their sport activity was restricted after TSA. In another retrospective case series (61 TSAs), McCarty and colleagues19 found that 48 patients (71%) were improved in their sports participation, and 50% increased their frequency of participation after surgery.
There are no specific recommendations on returning to military service or high-level sport after surgery. Recommendations on returning to sport after TSA have been based largely on small case series involving specific sports46,47 and surveys of expert opinion.17,18 In a survey on postoperative physical activity in young patients after TSA conducted by Healy and colleagues,17 35 American Shoulder and Elbow Surgeons members recommended avoiding contact and impact sports while permitting return to nonimpact sports, such as swimming, which may still impart significant stress to the glenohumeral joint. In an international survey of 101 shoulder and elbow surgeons, Magnussen and colleagues18 also found that most recommended avoiding a return to impact sports that require intensive upper extremity demands and permitting full return to sports at preoperative levels. This likely is a result of the perception that most of these patients having TSA are older and have less rigorous involvement in sports at the outset and a lower propensity for adverse patient outcomes. However, these recommendations may place a younger, more high-demand patient at significantly greater risk. The active-duty cohort engages in daily physical training, including push-ups and frequent overhead lifting, which could account for the high failure rates and low incidence of postoperative deployment. Although TSA seems to demonstrate good initial results in terms of return to high-demand activities, the return-to-duty profile in our study highlights the potential pitfalls of TSA in active individuals attempting to return to high-demand preoperative function.
Our analysis was limited by the fact that we used a small patient cohort, contributing to underpowered analysis of the potential risk factors predictive of reoperation and medical discharge. Although our minimum follow-up was 12 months, with the exception of 1 patient who was medically separated at 11.6 months because of shoulder disability, we captured 5 patients (19.2%) who underwent medical separation but who would otherwise be excluded. Therefore, this limitation is not major in that, with a longer minimum follow-up, we would be excluding a significant number of patients with such persistent disability after TSA that they would not be able to return to duty at anywhere near their previous level. In this retrospective study, we were additionally limited to analysis of the data in the medical records and could not control for variables such as surgeon technique, implant choice, and experience. Complete radiographic images were not available, limiting analysis of radiographic outcomes. Given the lack of a standardized preoperative imaging protocol, we could not evaluate glenoid version on axial imaging. It is possible that some patients with early aseptic glenoid loosening had posterior subluxation or a Walch B2 glenoid, which has a higher failure rate.48 The strengths of this study include its unique analysis of a homogeneous young, active, high-risk patient cohort within a closed healthcare system. In the military, these patients are subject to intense daily physical and occupational demands. In addition, the clinical and functional outcomes we studied are patient-centered and therefore relevant during preoperative counseling. Further investigations might focus on validated outcome measures and on midterm to long-term TSA outcomes in an active military population vis-à-vis other alternatives for clinical management.
Conclusion
By a mean follow-up of 3.5 years, only a third of the service members had returned to active duty, roughly a third had retired, and more than a third had been medically discharged because of persistent disability attributable to the shoulder. Despite initial improvements in ROM and pain, midterm outcomes were poor. The short-term complication rate (46.2%) and the rate of reoperation for component failure (23.1%) should be emphasized during preoperative counseling.
1. Tokish JM. The mature athlete’s shoulder. Sports Health. 2014;6(1):31-35.
2. Sperling JW, Cofield RH. Revision total shoulder arthroplasty for the treatment of glenoid arthrosis. J Bone Joint Surg Am. 1998;80(6):860-867.
3. Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck C, Cofield RH. Shoulder arthroplasty for arthritis after instability surgery. J Bone Joint Surg Am. 2002;84(10):1775-1781.
4. Izquierdo R, Voloshin I, Edwards S, et al; American Academy of Orthopaedic Surgeons. Treatment of glenohumeral osteoarthritis. J Am Acad Orthop Surg. 2010;18(6):375-382.
5. Johnson MH, Paxton ES, Green A. Shoulder arthroplasty options in young (<50 years old) patients: review of current concepts. J Shoulder Elbow Surg. 2015;24(2):317-325.
6. Cole BJ, Yanke A, Provencher MT. Nonarthroplasty alternatives for the treatment of glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16(5 suppl):S231-S240.
7. Denard PJ, Raiss P, Sowa B, Walch G. Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis. J Shoulder Elbow Surg. 2013;22(7):894-900.
8. Denard PJ, Wirth MA, Orfaly RM. Management of glenohumeral arthritis in the young adult. J Bone Joint Surg Am. 2011;93(9):885-892.
9. Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis. Arthroscopy. 2013;29(3):440-448.
10 Millett PJ, Gaskill TR. Arthroscopic management of glenohumeral arthrosis: humeral osteoplasty, capsular release, and arthroscopic axillary nerve release as a joint-preserving approach. Arthroscopy. 2011;27(9):1296-1303.
11. Savoie FH 3rd, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: midterm results. Arthroscopy. 2009;25(8):864-871.
12. Strauss EJ, Verma NN, Salata MJ, et al. The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2014;23(3):409-419.
13. Matsen FA 3rd, Warme WJ, Jackins SE. Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad? Clin Orthop Relat Res. 2015;473(6):2088-2096.
14. Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87(10):2178-2185.
15. Wirth M, Tapscott RS, Southworth C, Rockwood CA Jr. Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study. J Bone Joint Surg Am. 2006;88(5):964-973.
16. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004;13(6):604-613.
17. Healy WL, Iorio R, Lemos MJ. Athletic activity after joint replacement. Am J Sports Med. 2001;29(3):377-388.
18. Magnussen RA, Mallon WJ, Willems WJ, Moorman CT 3rd. Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons. J Shoulder Elbow Surg. 2011;20(2):281-289.
19. McCarty EC, Marx RG, Maerz D, Altchek D, Warren RF. Sports participation after shoulder replacement surgery. Am J Sports Med. 2008;36(8):1577-1581.
20. Schmidt-Wiethoff R, Wolf P, Lehmann M, Habermeyer P. Physical activity after shoulder arthroplasty [in German]. Sportverletz Sportschaden. 2002;16(1):26-30.
21. Schumann K, Flury MP, Schwyzer HK, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med. 2010;38(10):2097-2105.
22. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am. 1998;80(4):464-473.
23. Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis. J Bone Joint Surg Br. 2008;90(6):764-769.
24. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011;20(1):123-130.
25. Waterman BR, Burns TC, McCriskin B, Kilcoyne K, Cameron KL, Owens BD. Outcomes after Bankart repair in a military population: predictors for surgical revision and long-term disability. Arthroscopy. 2014;30(2):172-177.
26. Waterman BR, Liu J, Newcomb R, Schoenfeld AJ, Orr JD, Belmont PJ Jr. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med. 2013;41(11):2545-2549.
27. Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860.
28. Dunn JC, Lanzi J, Kusnezov N, Bader J, Waterman BR, Belmont PJ Jr. Predictors of length of stay after elective total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(5):754-759.
29. Hayes PR, Flatow EL. Total shoulder arthroplasty in the young patient. Instr Course Lect. 2001;50;73-88.
30. Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Humeral head replacement for the treatment of osteoarthritis. J Bone Joint Surg Am. 2006;88(12):2637-2644.
31. Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007;16(4):396-402.
32. Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am. 2000;82(1):26-34.
33. Edwards TB, Kadakia NR, Boulahia A, et al. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg. 2003;12(3):
207-213.
34. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(9):1947-1956.
35. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. J Bone Joint Surg Am. 2008;90(1):110-117.
36. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft interposition arthroplasty for the arthritic shoulder: description of a new surgical technique. Tech Shoulder Elbow Surg. 2001;2:247-254.
37. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am. 2009;91(2):419-424.
38. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes. J Bone Joint Surg Am. 2007;89(4):727-734.
39. Lee KT, Bell S, Salmon J. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. J Shoulder Elbow Surg. 2009;18(6):915-919.
40. Nicholson GP, Goldstein JL, Romeo AA, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. J Shoulder Elbow Surg. 2007;16(5 suppl):S261-S266.
41. Carroll RM, Izquierdo R, Vazquez M, Blaine TA, Levine WN, Bigliani LU. Conversion of painful hemiarthroplasty to total shoulder arthroplasty: long-term results. J Shoulder Elbow Surg. 2004;13(6):599-603.
42. Clinton J, Franta AK, Lenters TR, Mounce D, Matsen FA 3rd. Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16(5):534-538.
43. Gilmer BB, Comstock BA, Jette JL, Warme WJ, Jackins SE, Matsen FA. The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases. J Bone Joint Surg Am. 2012;94(14):e102.
44. Franta AK, Lenters TR, Mounce D, Neradilek B, Matsen FA 3rd. The complex characteristics of 282 unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg. 2007;16(5):555-562.
45. Godenèche A, Boileau P, Favard L, et al. Prosthetic replacement in the treatment of osteoarthritis of the shoulder: early results of 268 cases. J Shoulder Elbow Surg. 2002;11(1):11-18.
46. Jensen KL, Rockwood CA Jr. Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg. 1998;7(4):362-367.
47. Kirchhoff C, Imhoff AB, Hinterwimmer S. Winter sports and shoulder arthroplasty [in German]. Sportverletz Sportschaden. 2008;22(3):153-158.
48. Raiss P, Edwards TB, Deutsch A, et al. Radiographic changes around humeral components in shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(7):e54.
1. Tokish JM. The mature athlete’s shoulder. Sports Health. 2014;6(1):31-35.
2. Sperling JW, Cofield RH. Revision total shoulder arthroplasty for the treatment of glenoid arthrosis. J Bone Joint Surg Am. 1998;80(6):860-867.
3. Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck C, Cofield RH. Shoulder arthroplasty for arthritis after instability surgery. J Bone Joint Surg Am. 2002;84(10):1775-1781.
4. Izquierdo R, Voloshin I, Edwards S, et al; American Academy of Orthopaedic Surgeons. Treatment of glenohumeral osteoarthritis. J Am Acad Orthop Surg. 2010;18(6):375-382.
5. Johnson MH, Paxton ES, Green A. Shoulder arthroplasty options in young (<50 years old) patients: review of current concepts. J Shoulder Elbow Surg. 2015;24(2):317-325.
6. Cole BJ, Yanke A, Provencher MT. Nonarthroplasty alternatives for the treatment of glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16(5 suppl):S231-S240.
7. Denard PJ, Raiss P, Sowa B, Walch G. Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis. J Shoulder Elbow Surg. 2013;22(7):894-900.
8. Denard PJ, Wirth MA, Orfaly RM. Management of glenohumeral arthritis in the young adult. J Bone Joint Surg Am. 2011;93(9):885-892.
9. Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis. Arthroscopy. 2013;29(3):440-448.
10 Millett PJ, Gaskill TR. Arthroscopic management of glenohumeral arthrosis: humeral osteoplasty, capsular release, and arthroscopic axillary nerve release as a joint-preserving approach. Arthroscopy. 2011;27(9):1296-1303.
11. Savoie FH 3rd, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: midterm results. Arthroscopy. 2009;25(8):864-871.
12. Strauss EJ, Verma NN, Salata MJ, et al. The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2014;23(3):409-419.
13. Matsen FA 3rd, Warme WJ, Jackins SE. Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad? Clin Orthop Relat Res. 2015;473(6):2088-2096.
14. Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87(10):2178-2185.
15. Wirth M, Tapscott RS, Southworth C, Rockwood CA Jr. Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study. J Bone Joint Surg Am. 2006;88(5):964-973.
16. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg. 2004;13(6):604-613.
17. Healy WL, Iorio R, Lemos MJ. Athletic activity after joint replacement. Am J Sports Med. 2001;29(3):377-388.
18. Magnussen RA, Mallon WJ, Willems WJ, Moorman CT 3rd. Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons. J Shoulder Elbow Surg. 2011;20(2):281-289.
19. McCarty EC, Marx RG, Maerz D, Altchek D, Warren RF. Sports participation after shoulder replacement surgery. Am J Sports Med. 2008;36(8):1577-1581.
20. Schmidt-Wiethoff R, Wolf P, Lehmann M, Habermeyer P. Physical activity after shoulder arthroplasty [in German]. Sportverletz Sportschaden. 2002;16(1):26-30.
21. Schumann K, Flury MP, Schwyzer HK, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med. 2010;38(10):2097-2105.
22. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am. 1998;80(4):464-473.
23. Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis. J Bone Joint Surg Br. 2008;90(6):764-769.
24. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011;20(1):123-130.
25. Waterman BR, Burns TC, McCriskin B, Kilcoyne K, Cameron KL, Owens BD. Outcomes after Bankart repair in a military population: predictors for surgical revision and long-term disability. Arthroscopy. 2014;30(2):172-177.
26. Waterman BR, Liu J, Newcomb R, Schoenfeld AJ, Orr JD, Belmont PJ Jr. Risk factors for chronic exertional compartment syndrome in a physically active military population. Am J Sports Med. 2013;41(11):2545-2549.
27. Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860.
28. Dunn JC, Lanzi J, Kusnezov N, Bader J, Waterman BR, Belmont PJ Jr. Predictors of length of stay after elective total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015;24(5):754-759.
29. Hayes PR, Flatow EL. Total shoulder arthroplasty in the young patient. Instr Course Lect. 2001;50;73-88.
30. Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Humeral head replacement for the treatment of osteoarthritis. J Bone Joint Surg Am. 2006;88(12):2637-2644.
31. Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CS. Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review. J Shoulder Elbow Surg. 2007;16(4):396-402.
32. Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am. 2000;82(1):26-34.
33. Edwards TB, Kadakia NR, Boulahia A, et al. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg. 2003;12(3):
207-213.
34. Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am. 2005;87(9):1947-1956.
35. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. J Bone Joint Surg Am. 2008;90(1):110-117.
36. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft interposition arthroplasty for the arthritic shoulder: description of a new surgical technique. Tech Shoulder Elbow Surg. 2001;2:247-254.
37. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am. 2009;91(2):419-424.
38. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes. J Bone Joint Surg Am. 2007;89(4):727-734.
39. Lee KT, Bell S, Salmon J. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. J Shoulder Elbow Surg. 2009;18(6):915-919.
40. Nicholson GP, Goldstein JL, Romeo AA, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. J Shoulder Elbow Surg. 2007;16(5 suppl):S261-S266.
41. Carroll RM, Izquierdo R, Vazquez M, Blaine TA, Levine WN, Bigliani LU. Conversion of painful hemiarthroplasty to total shoulder arthroplasty: long-term results. J Shoulder Elbow Surg. 2004;13(6):599-603.
42. Clinton J, Franta AK, Lenters TR, Mounce D, Matsen FA 3rd. Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16(5):534-538.
43. Gilmer BB, Comstock BA, Jette JL, Warme WJ, Jackins SE, Matsen FA. The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases. J Bone Joint Surg Am. 2012;94(14):e102.
44. Franta AK, Lenters TR, Mounce D, Neradilek B, Matsen FA 3rd. The complex characteristics of 282 unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg. 2007;16(5):555-562.
45. Godenèche A, Boileau P, Favard L, et al. Prosthetic replacement in the treatment of osteoarthritis of the shoulder: early results of 268 cases. J Shoulder Elbow Surg. 2002;11(1):11-18.
46. Jensen KL, Rockwood CA Jr. Shoulder arthroplasty in recreational golfers. J Shoulder Elbow Surg. 1998;7(4):362-367.
47. Kirchhoff C, Imhoff AB, Hinterwimmer S. Winter sports and shoulder arthroplasty [in German]. Sportverletz Sportschaden. 2008;22(3):153-158.
48. Raiss P, Edwards TB, Deutsch A, et al. Radiographic changes around humeral components in shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(7):e54.
Technique of Open Reduction and Internal Fixation of Comminuted Proximal Humerus Fractures With Allograft Femoral Head Metaphyseal Reconstruction
Proximal humerus fractures are exceedingly common and account for almost 5% of all fractures. As osteoporosis is a risk factor for these fractures, their incidence rises with patient age.1
In 1970, Neer2 described these type of fractures and classified them as having 2, 3, or 4 parts based on the amount of angulation and displacement of the humeral head and the greater and lesser tuberosities with respect to the shaft.
Three- and 4-part proximal humerus fractures can be treated either nonoperatively, or surgically with closed reduction and percutaneous fixation, intramedullary fixation, open reduction and internal fixation (ORIF), or arthroplasty. There remains controversy over the best treatment, but a key component of any surgical treatment is anatomical reduction, stable fixation, and then healing of the tuberosities. A current common form of treatment is augmentation with an allograft fibula placed in the medullary canal. Although not formally reported, anecdotal evidence demonstrates that revision to arthroplasty is very difficult in the setting of an ingrown graft in the medullary canal of the humerus.
In this article, we present a novel technique of using allograft femoral head to reconstruct the metaphysis in ORIF of comminuted proximal humerus fractures.
Technique
Presented in Figure 1 are preoperative images of a representative displaced 4-part proximal humerus fracture treated surgically using the technique described here. General anesthesia is used. After intubation on the operating table, the patient is placed in the beach-chair position with about 75° of hip flexion. All bony prominences are padded, and the head and trunk are well secured. A pneumatic arm positioner is used to alleviate the need for an assistant to manipulate the arm. An image intensifier is used before preparing to verify that appropriate images of the proximal humerus can be obtained. Once adequate images are confirmed, the floor can be marked at the position of the fluoroscopic unit’s wheels to allow easy reproduction of images once the arm is prepared and draped. The intensifier is then removed from the field, the shoulder is prepared and draped in usual fashion, and prophylactic antibiotics are administered.
A deltopectoral incision is used, and sharp dissection is made through the subcutaneous tissue to raise full-thickness subcutaneous flaps on each side. The deltopectoral interval is sharply dissected while protecting the cephalic vein. Subdeltoid adhesions are then released. Palpation of the axillary nerve in the quadrilateral space to identify its location is helpful to avoid injury during the procedure.
The fracture is then identified, and No. 5 permanent suture is placed through the posterior and superior rotator cuff and through the subscapularis insertion (Figure 2). The tuberosities are freed from the humeral head sharply. A blunt elevator is then used to gently elevate the humeral head upward, with care taken to avoid comminuting the metaphyseal bone while levering. Reduction is achieved by manipulating the sutures and levering the head with the elevator while placing the arm in extension and posterior translation. Fluoroscopic images are used to verify correct anatomical alignment. Generally, the metaphysis demonstrates comminution and impaction, with poor bone quality necessitating use of bone graft.
A frozen allograft femoral head is then obtained and split into 2 equal pieces using a saw (Figures 3–5). One piece is fashioned with a saw and a burr into a trapezoid such that the proximal portion is wider, and the distal, tapered portion is sized to fit the canal. The broad, proximal portion of the graft will serve as a pedestal to reduce the head to the shaft. Measuring the internal diameter of the humeral canal can be useful in estimating the necessary dimensions of the distal portion of the allograft. The graft often needs several small adjustments that necessitate attempting to place it in the intramedullary canal and then trimming as necessary to ensure proper fit distally within the shaft. For this reason, it is beneficial to perform the graft preparation near the surgical field. Once completed, the distal portion is then impacted into the humeral canal (Figure 6). Because of this impaction, there is no possibility for subsidence or pistoning of the graft within the canal, which can occur with a fibular graft. The humeral head is reduced onto the shaft with the already placed sutures; this is achieved by abducting the shoulder. The image intensifier is then used to confirm appropriate alignment and positioning of the fragments, making sure that both neck–shaft angle and medial calcar alignment have been restored (Figures 7, 8).
An appropriately sized proximal humerus plate is then selected based on the location of the fracture line. We have used standard lateral proximal humerus locking plates as well as laterality-specific anterolateral proximal humerus plates and found that both are suitable for incorporation of the screws through the graft and into the head. The plate is positioned on the humerus, and a guide pin is placed by hand through the proximal-most hole so that the appropriate height of the plate can be verified on fluoroscopy. The first screw is then a nonlocking bicortical screw placed through the oval hole in the shaft of the plate to allow further fine manipulation of the plate more proximally or distally as needed. The final height is confirmed, and the screw is firmly tightened (Figure 9). The locking-screw guide is fixed to the proximal portion of the plate, and 2 locking screws are then placed into the head. The arm is then rotated to an anteroposterior view by placing the arm in external rotation and neutral flexion and is then abducted and internally rotated to recreate a lateral view to perform final verification of the position of the plate on orthogonal images. If the surgeon is satisfied with the position of the plate, another nonlocking screw is placed distally, and then the proximal holes are used to place locking screws as needed. If the surgeon is not satisfied, the 2 proximal screws can be removed and the plate repositioned.
After each screw is placed, fluoroscopy is used to ensure there has been no breach of the articular surface. The number of proximal screws placed depends on fracture configuration and surgeon preference.
The sutures through the rotator cuff are then fixed to the plate, securing the tuberosities. Final intraoperative radiographs are used to confirm reduction, alignment, and final position of hardware (Figure 10). After copious irrigation, a surgical drain is placed as needed, and the wound is closed in layered fashion. Three years after surgery, follow-up examination revealed no radiographic change in alignment, no necrosis, and no varus collapse (Figure 11), and the patient was pain-free during activities.
Discussion
Surgical treatment of comminuted proximal humerus fractures usually consists of some type of plate fixation with screw fixation of the shaft, screws or smooth pegs to support the chondral surfaces, and screw fixation or suture cerclage of the tuberosities.
Fixed-angle locking-plate-and-screw constructs increased the biomechanical stability and pullout strength of proximal humerus plates.3,4 Nevertheless, avascular necrosis, malunion, and nonunion are still known complications of proximal humerus fractures, especially those with comminution, with up to 14% of patients still experiencing loss of fixation.5
For this reason, several authors have proposed using allograft bone and/or augmentation with calcium-containing cement to supplement fixation and provide an endosteal form of support for the head and tuberosities to decrease the risk for varus collapse. Osteobiologics (eg, calcium phosphate or sulfate cement) have been shown to decrease the risk for loss of reduction of proximal humerus fractures and decrease the risk for intra-articular screw penetration.6,7 Many calcium phosphate cements are commercially available. Cost and availability are 2 reasons that these supplements are not more widely used. Cancellous chips have also been used to aid in the reduction of proximal humerus fractures.8 No randomized study has been conducted to show a clinical advantage of this technique, though retrospective studies have shown that it is not as advantageous as using calcium phosphate cement with respect to loss of reduction or screw penetration.6 Certainly, cancellous chips are easily available in most hospitals and are less expensive than some alternatives. A recent review of these techniques in osteoporotic proximal humerus fractures found no clear indication for using one of these supplements over another.9
However, some fracture patterns require a structural graft to reduce the tuberosities and head component. Although described more than 30 years ago as a treatment for nonunions with an intramedullary “peg” of iliac crest graft,10 the graft most commonly reported today is allograft fibula.11-15 This technique consists of preparing the humeral shaft and often the fractured head segment with reaming to create a channel to receive the graft. Even with use of a small fibula, it is often time-consuming to use a saw, rasp, or burr to size the fibular segment to fit the medullary canal of the humerus. Once in place, the graft provides a strut on which the head fragment can be reduced and around which the tuberosities can be reduced. Although this technique is successful clinically and is biomechanically superior to plate-only constructs,16,17 concerns remain.
One such concern is keeping this graft in routine supply at most hospitals. Supply and pricing from vendors can differ significantly between hospitals, and a surgeon may need to request grafts in advance, which makes their use nonviable in a trauma case. Certain grafts are often kept in routine supply based on their overall utilization. At our institution, allograft femoral heads meet this criterion and are routinely stocked.
Of more importance are the ramifications of these procedures for future revision surgeries. The need for arthroplasty revision is common after ORIF of a proximal humerus fracture.18
Arthroplasty revision is an already challenging procedure that becomes more complex with the need to remove 6 to 8 cm of ingrown endosteal bone from a shell of outer osteoporotic cortical bone. Our experience with these complex revisions provided the impetus to search for an alternate graft type that still provides a strut for reducing the head and tuberosities but limits the amount of endosteal bone that would need to be removed in arthroplasty revision in order to place a stemmed component into the humeral canal.
Some currently available arthroplasty fracture systems modify the previous anatomy of the stem to provide a more anatomical platform to reduce the tuberosities to a broader metaphyseal construct that incorporates bone grafting to assist with healing.
Because of these concerns and factors, we adapted our technique to create an individual-specific pedestal with allograft femoral head that can be anatomically matched to each patient. This provides a strut to reduce the head and tuberosity fragments but still limits the amount of allograft bone needed to seat into the existing canal. The geometry of the allograft can also be customized to the fracture, with most 3- and 4-part fractures needing a trapezoidal strut that resembles the metaphyseal portion of a fracture-specific shoulder arthroplasty implant.
We have used this technique for comminuted 3- and 4-part fractures of the proximal humerus in 14 cases with at least 2-year follow-up and in several more cases that have not reached 2-year follow-up. All cases have gone on to radiographic union; none have had to be revised either with revision ORIF or to an arthroplasty. Formal measurements of final postoperative range of motion have not been tabulated in all cases, as some cases have been lost to follow-up after radiographic union was achieved. Medium- and long-term results are not yet available, but no short-term complications have been noted.
Disadvantages of this technique are that, while an individualized graft is created, proper shaping still takes time, and a moderate amount of the femoral head is not used. However, we have found that, if a graft is inadvertently undersized, there is still ample femoral head remaining to create another sized graft. Other disadvantages are the added cost and the (rare) risk of disease transmission, which come with use of any allograft, but the technique is used instead of another type of allograft, so these disadvantages are largely equivalent. At our hospital, differences in cost and availability between femoral head or fibular allografts are negligible.
This procedure, which is easily performed in a short amount of time, allows a stable base of bone graft to be used as an aid in the anatomical reduction of proximal humerus fractures, without the need for reaming and preparation of the medullary canal and without further increasing the difficulty associated with a future revision procedure.
1. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-249.
2. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
3. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg. 2000;9(5):423-426.
4. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elbow Surg. 2006;15(2):239-243.
5. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681.
6. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741-748.
7. Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma. 2013;27(7):399-404.
8. Ong CC, Kwon YW, Walsh M, Davidovitch R, Zuckerman JD, Egol KA. Outcomes of open reduction and internal fixation of proximal humerus fractures managed with locking plates. Am J Orthop. 2012;41(9):407-412.
9. Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012;21(12):1787-1795.
10. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res. 1982;(167):255-259.
11. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212-215.
12. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300-3306.
13. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195-200.
14. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942.
15. Little MT, Berkes MB, Schottel PC, et al. The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma. 2014;28(6):338-347.
16. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech. 2010;25(7):642-646.
17. Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg. 2012;21(7):894-901.
18. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542-549.
Proximal humerus fractures are exceedingly common and account for almost 5% of all fractures. As osteoporosis is a risk factor for these fractures, their incidence rises with patient age.1
In 1970, Neer2 described these type of fractures and classified them as having 2, 3, or 4 parts based on the amount of angulation and displacement of the humeral head and the greater and lesser tuberosities with respect to the shaft.
Three- and 4-part proximal humerus fractures can be treated either nonoperatively, or surgically with closed reduction and percutaneous fixation, intramedullary fixation, open reduction and internal fixation (ORIF), or arthroplasty. There remains controversy over the best treatment, but a key component of any surgical treatment is anatomical reduction, stable fixation, and then healing of the tuberosities. A current common form of treatment is augmentation with an allograft fibula placed in the medullary canal. Although not formally reported, anecdotal evidence demonstrates that revision to arthroplasty is very difficult in the setting of an ingrown graft in the medullary canal of the humerus.
In this article, we present a novel technique of using allograft femoral head to reconstruct the metaphysis in ORIF of comminuted proximal humerus fractures.
Technique
Presented in Figure 1 are preoperative images of a representative displaced 4-part proximal humerus fracture treated surgically using the technique described here. General anesthesia is used. After intubation on the operating table, the patient is placed in the beach-chair position with about 75° of hip flexion. All bony prominences are padded, and the head and trunk are well secured. A pneumatic arm positioner is used to alleviate the need for an assistant to manipulate the arm. An image intensifier is used before preparing to verify that appropriate images of the proximal humerus can be obtained. Once adequate images are confirmed, the floor can be marked at the position of the fluoroscopic unit’s wheels to allow easy reproduction of images once the arm is prepared and draped. The intensifier is then removed from the field, the shoulder is prepared and draped in usual fashion, and prophylactic antibiotics are administered.
A deltopectoral incision is used, and sharp dissection is made through the subcutaneous tissue to raise full-thickness subcutaneous flaps on each side. The deltopectoral interval is sharply dissected while protecting the cephalic vein. Subdeltoid adhesions are then released. Palpation of the axillary nerve in the quadrilateral space to identify its location is helpful to avoid injury during the procedure.
The fracture is then identified, and No. 5 permanent suture is placed through the posterior and superior rotator cuff and through the subscapularis insertion (Figure 2). The tuberosities are freed from the humeral head sharply. A blunt elevator is then used to gently elevate the humeral head upward, with care taken to avoid comminuting the metaphyseal bone while levering. Reduction is achieved by manipulating the sutures and levering the head with the elevator while placing the arm in extension and posterior translation. Fluoroscopic images are used to verify correct anatomical alignment. Generally, the metaphysis demonstrates comminution and impaction, with poor bone quality necessitating use of bone graft.
A frozen allograft femoral head is then obtained and split into 2 equal pieces using a saw (Figures 3–5). One piece is fashioned with a saw and a burr into a trapezoid such that the proximal portion is wider, and the distal, tapered portion is sized to fit the canal. The broad, proximal portion of the graft will serve as a pedestal to reduce the head to the shaft. Measuring the internal diameter of the humeral canal can be useful in estimating the necessary dimensions of the distal portion of the allograft. The graft often needs several small adjustments that necessitate attempting to place it in the intramedullary canal and then trimming as necessary to ensure proper fit distally within the shaft. For this reason, it is beneficial to perform the graft preparation near the surgical field. Once completed, the distal portion is then impacted into the humeral canal (Figure 6). Because of this impaction, there is no possibility for subsidence or pistoning of the graft within the canal, which can occur with a fibular graft. The humeral head is reduced onto the shaft with the already placed sutures; this is achieved by abducting the shoulder. The image intensifier is then used to confirm appropriate alignment and positioning of the fragments, making sure that both neck–shaft angle and medial calcar alignment have been restored (Figures 7, 8).
An appropriately sized proximal humerus plate is then selected based on the location of the fracture line. We have used standard lateral proximal humerus locking plates as well as laterality-specific anterolateral proximal humerus plates and found that both are suitable for incorporation of the screws through the graft and into the head. The plate is positioned on the humerus, and a guide pin is placed by hand through the proximal-most hole so that the appropriate height of the plate can be verified on fluoroscopy. The first screw is then a nonlocking bicortical screw placed through the oval hole in the shaft of the plate to allow further fine manipulation of the plate more proximally or distally as needed. The final height is confirmed, and the screw is firmly tightened (Figure 9). The locking-screw guide is fixed to the proximal portion of the plate, and 2 locking screws are then placed into the head. The arm is then rotated to an anteroposterior view by placing the arm in external rotation and neutral flexion and is then abducted and internally rotated to recreate a lateral view to perform final verification of the position of the plate on orthogonal images. If the surgeon is satisfied with the position of the plate, another nonlocking screw is placed distally, and then the proximal holes are used to place locking screws as needed. If the surgeon is not satisfied, the 2 proximal screws can be removed and the plate repositioned.
After each screw is placed, fluoroscopy is used to ensure there has been no breach of the articular surface. The number of proximal screws placed depends on fracture configuration and surgeon preference.
The sutures through the rotator cuff are then fixed to the plate, securing the tuberosities. Final intraoperative radiographs are used to confirm reduction, alignment, and final position of hardware (Figure 10). After copious irrigation, a surgical drain is placed as needed, and the wound is closed in layered fashion. Three years after surgery, follow-up examination revealed no radiographic change in alignment, no necrosis, and no varus collapse (Figure 11), and the patient was pain-free during activities.
Discussion
Surgical treatment of comminuted proximal humerus fractures usually consists of some type of plate fixation with screw fixation of the shaft, screws or smooth pegs to support the chondral surfaces, and screw fixation or suture cerclage of the tuberosities.
Fixed-angle locking-plate-and-screw constructs increased the biomechanical stability and pullout strength of proximal humerus plates.3,4 Nevertheless, avascular necrosis, malunion, and nonunion are still known complications of proximal humerus fractures, especially those with comminution, with up to 14% of patients still experiencing loss of fixation.5
For this reason, several authors have proposed using allograft bone and/or augmentation with calcium-containing cement to supplement fixation and provide an endosteal form of support for the head and tuberosities to decrease the risk for varus collapse. Osteobiologics (eg, calcium phosphate or sulfate cement) have been shown to decrease the risk for loss of reduction of proximal humerus fractures and decrease the risk for intra-articular screw penetration.6,7 Many calcium phosphate cements are commercially available. Cost and availability are 2 reasons that these supplements are not more widely used. Cancellous chips have also been used to aid in the reduction of proximal humerus fractures.8 No randomized study has been conducted to show a clinical advantage of this technique, though retrospective studies have shown that it is not as advantageous as using calcium phosphate cement with respect to loss of reduction or screw penetration.6 Certainly, cancellous chips are easily available in most hospitals and are less expensive than some alternatives. A recent review of these techniques in osteoporotic proximal humerus fractures found no clear indication for using one of these supplements over another.9
However, some fracture patterns require a structural graft to reduce the tuberosities and head component. Although described more than 30 years ago as a treatment for nonunions with an intramedullary “peg” of iliac crest graft,10 the graft most commonly reported today is allograft fibula.11-15 This technique consists of preparing the humeral shaft and often the fractured head segment with reaming to create a channel to receive the graft. Even with use of a small fibula, it is often time-consuming to use a saw, rasp, or burr to size the fibular segment to fit the medullary canal of the humerus. Once in place, the graft provides a strut on which the head fragment can be reduced and around which the tuberosities can be reduced. Although this technique is successful clinically and is biomechanically superior to plate-only constructs,16,17 concerns remain.
One such concern is keeping this graft in routine supply at most hospitals. Supply and pricing from vendors can differ significantly between hospitals, and a surgeon may need to request grafts in advance, which makes their use nonviable in a trauma case. Certain grafts are often kept in routine supply based on their overall utilization. At our institution, allograft femoral heads meet this criterion and are routinely stocked.
Of more importance are the ramifications of these procedures for future revision surgeries. The need for arthroplasty revision is common after ORIF of a proximal humerus fracture.18
Arthroplasty revision is an already challenging procedure that becomes more complex with the need to remove 6 to 8 cm of ingrown endosteal bone from a shell of outer osteoporotic cortical bone. Our experience with these complex revisions provided the impetus to search for an alternate graft type that still provides a strut for reducing the head and tuberosities but limits the amount of endosteal bone that would need to be removed in arthroplasty revision in order to place a stemmed component into the humeral canal.
Some currently available arthroplasty fracture systems modify the previous anatomy of the stem to provide a more anatomical platform to reduce the tuberosities to a broader metaphyseal construct that incorporates bone grafting to assist with healing.
Because of these concerns and factors, we adapted our technique to create an individual-specific pedestal with allograft femoral head that can be anatomically matched to each patient. This provides a strut to reduce the head and tuberosity fragments but still limits the amount of allograft bone needed to seat into the existing canal. The geometry of the allograft can also be customized to the fracture, with most 3- and 4-part fractures needing a trapezoidal strut that resembles the metaphyseal portion of a fracture-specific shoulder arthroplasty implant.
We have used this technique for comminuted 3- and 4-part fractures of the proximal humerus in 14 cases with at least 2-year follow-up and in several more cases that have not reached 2-year follow-up. All cases have gone on to radiographic union; none have had to be revised either with revision ORIF or to an arthroplasty. Formal measurements of final postoperative range of motion have not been tabulated in all cases, as some cases have been lost to follow-up after radiographic union was achieved. Medium- and long-term results are not yet available, but no short-term complications have been noted.
Disadvantages of this technique are that, while an individualized graft is created, proper shaping still takes time, and a moderate amount of the femoral head is not used. However, we have found that, if a graft is inadvertently undersized, there is still ample femoral head remaining to create another sized graft. Other disadvantages are the added cost and the (rare) risk of disease transmission, which come with use of any allograft, but the technique is used instead of another type of allograft, so these disadvantages are largely equivalent. At our hospital, differences in cost and availability between femoral head or fibular allografts are negligible.
This procedure, which is easily performed in a short amount of time, allows a stable base of bone graft to be used as an aid in the anatomical reduction of proximal humerus fractures, without the need for reaming and preparation of the medullary canal and without further increasing the difficulty associated with a future revision procedure.
Proximal humerus fractures are exceedingly common and account for almost 5% of all fractures. As osteoporosis is a risk factor for these fractures, their incidence rises with patient age.1
In 1970, Neer2 described these type of fractures and classified them as having 2, 3, or 4 parts based on the amount of angulation and displacement of the humeral head and the greater and lesser tuberosities with respect to the shaft.
Three- and 4-part proximal humerus fractures can be treated either nonoperatively, or surgically with closed reduction and percutaneous fixation, intramedullary fixation, open reduction and internal fixation (ORIF), or arthroplasty. There remains controversy over the best treatment, but a key component of any surgical treatment is anatomical reduction, stable fixation, and then healing of the tuberosities. A current common form of treatment is augmentation with an allograft fibula placed in the medullary canal. Although not formally reported, anecdotal evidence demonstrates that revision to arthroplasty is very difficult in the setting of an ingrown graft in the medullary canal of the humerus.
In this article, we present a novel technique of using allograft femoral head to reconstruct the metaphysis in ORIF of comminuted proximal humerus fractures.
Technique
Presented in Figure 1 are preoperative images of a representative displaced 4-part proximal humerus fracture treated surgically using the technique described here. General anesthesia is used. After intubation on the operating table, the patient is placed in the beach-chair position with about 75° of hip flexion. All bony prominences are padded, and the head and trunk are well secured. A pneumatic arm positioner is used to alleviate the need for an assistant to manipulate the arm. An image intensifier is used before preparing to verify that appropriate images of the proximal humerus can be obtained. Once adequate images are confirmed, the floor can be marked at the position of the fluoroscopic unit’s wheels to allow easy reproduction of images once the arm is prepared and draped. The intensifier is then removed from the field, the shoulder is prepared and draped in usual fashion, and prophylactic antibiotics are administered.
A deltopectoral incision is used, and sharp dissection is made through the subcutaneous tissue to raise full-thickness subcutaneous flaps on each side. The deltopectoral interval is sharply dissected while protecting the cephalic vein. Subdeltoid adhesions are then released. Palpation of the axillary nerve in the quadrilateral space to identify its location is helpful to avoid injury during the procedure.
The fracture is then identified, and No. 5 permanent suture is placed through the posterior and superior rotator cuff and through the subscapularis insertion (Figure 2). The tuberosities are freed from the humeral head sharply. A blunt elevator is then used to gently elevate the humeral head upward, with care taken to avoid comminuting the metaphyseal bone while levering. Reduction is achieved by manipulating the sutures and levering the head with the elevator while placing the arm in extension and posterior translation. Fluoroscopic images are used to verify correct anatomical alignment. Generally, the metaphysis demonstrates comminution and impaction, with poor bone quality necessitating use of bone graft.
A frozen allograft femoral head is then obtained and split into 2 equal pieces using a saw (Figures 3–5). One piece is fashioned with a saw and a burr into a trapezoid such that the proximal portion is wider, and the distal, tapered portion is sized to fit the canal. The broad, proximal portion of the graft will serve as a pedestal to reduce the head to the shaft. Measuring the internal diameter of the humeral canal can be useful in estimating the necessary dimensions of the distal portion of the allograft. The graft often needs several small adjustments that necessitate attempting to place it in the intramedullary canal and then trimming as necessary to ensure proper fit distally within the shaft. For this reason, it is beneficial to perform the graft preparation near the surgical field. Once completed, the distal portion is then impacted into the humeral canal (Figure 6). Because of this impaction, there is no possibility for subsidence or pistoning of the graft within the canal, which can occur with a fibular graft. The humeral head is reduced onto the shaft with the already placed sutures; this is achieved by abducting the shoulder. The image intensifier is then used to confirm appropriate alignment and positioning of the fragments, making sure that both neck–shaft angle and medial calcar alignment have been restored (Figures 7, 8).
An appropriately sized proximal humerus plate is then selected based on the location of the fracture line. We have used standard lateral proximal humerus locking plates as well as laterality-specific anterolateral proximal humerus plates and found that both are suitable for incorporation of the screws through the graft and into the head. The plate is positioned on the humerus, and a guide pin is placed by hand through the proximal-most hole so that the appropriate height of the plate can be verified on fluoroscopy. The first screw is then a nonlocking bicortical screw placed through the oval hole in the shaft of the plate to allow further fine manipulation of the plate more proximally or distally as needed. The final height is confirmed, and the screw is firmly tightened (Figure 9). The locking-screw guide is fixed to the proximal portion of the plate, and 2 locking screws are then placed into the head. The arm is then rotated to an anteroposterior view by placing the arm in external rotation and neutral flexion and is then abducted and internally rotated to recreate a lateral view to perform final verification of the position of the plate on orthogonal images. If the surgeon is satisfied with the position of the plate, another nonlocking screw is placed distally, and then the proximal holes are used to place locking screws as needed. If the surgeon is not satisfied, the 2 proximal screws can be removed and the plate repositioned.
After each screw is placed, fluoroscopy is used to ensure there has been no breach of the articular surface. The number of proximal screws placed depends on fracture configuration and surgeon preference.
The sutures through the rotator cuff are then fixed to the plate, securing the tuberosities. Final intraoperative radiographs are used to confirm reduction, alignment, and final position of hardware (Figure 10). After copious irrigation, a surgical drain is placed as needed, and the wound is closed in layered fashion. Three years after surgery, follow-up examination revealed no radiographic change in alignment, no necrosis, and no varus collapse (Figure 11), and the patient was pain-free during activities.
Discussion
Surgical treatment of comminuted proximal humerus fractures usually consists of some type of plate fixation with screw fixation of the shaft, screws or smooth pegs to support the chondral surfaces, and screw fixation or suture cerclage of the tuberosities.
Fixed-angle locking-plate-and-screw constructs increased the biomechanical stability and pullout strength of proximal humerus plates.3,4 Nevertheless, avascular necrosis, malunion, and nonunion are still known complications of proximal humerus fractures, especially those with comminution, with up to 14% of patients still experiencing loss of fixation.5
For this reason, several authors have proposed using allograft bone and/or augmentation with calcium-containing cement to supplement fixation and provide an endosteal form of support for the head and tuberosities to decrease the risk for varus collapse. Osteobiologics (eg, calcium phosphate or sulfate cement) have been shown to decrease the risk for loss of reduction of proximal humerus fractures and decrease the risk for intra-articular screw penetration.6,7 Many calcium phosphate cements are commercially available. Cost and availability are 2 reasons that these supplements are not more widely used. Cancellous chips have also been used to aid in the reduction of proximal humerus fractures.8 No randomized study has been conducted to show a clinical advantage of this technique, though retrospective studies have shown that it is not as advantageous as using calcium phosphate cement with respect to loss of reduction or screw penetration.6 Certainly, cancellous chips are easily available in most hospitals and are less expensive than some alternatives. A recent review of these techniques in osteoporotic proximal humerus fractures found no clear indication for using one of these supplements over another.9
However, some fracture patterns require a structural graft to reduce the tuberosities and head component. Although described more than 30 years ago as a treatment for nonunions with an intramedullary “peg” of iliac crest graft,10 the graft most commonly reported today is allograft fibula.11-15 This technique consists of preparing the humeral shaft and often the fractured head segment with reaming to create a channel to receive the graft. Even with use of a small fibula, it is often time-consuming to use a saw, rasp, or burr to size the fibular segment to fit the medullary canal of the humerus. Once in place, the graft provides a strut on which the head fragment can be reduced and around which the tuberosities can be reduced. Although this technique is successful clinically and is biomechanically superior to plate-only constructs,16,17 concerns remain.
One such concern is keeping this graft in routine supply at most hospitals. Supply and pricing from vendors can differ significantly between hospitals, and a surgeon may need to request grafts in advance, which makes their use nonviable in a trauma case. Certain grafts are often kept in routine supply based on their overall utilization. At our institution, allograft femoral heads meet this criterion and are routinely stocked.
Of more importance are the ramifications of these procedures for future revision surgeries. The need for arthroplasty revision is common after ORIF of a proximal humerus fracture.18
Arthroplasty revision is an already challenging procedure that becomes more complex with the need to remove 6 to 8 cm of ingrown endosteal bone from a shell of outer osteoporotic cortical bone. Our experience with these complex revisions provided the impetus to search for an alternate graft type that still provides a strut for reducing the head and tuberosities but limits the amount of endosteal bone that would need to be removed in arthroplasty revision in order to place a stemmed component into the humeral canal.
Some currently available arthroplasty fracture systems modify the previous anatomy of the stem to provide a more anatomical platform to reduce the tuberosities to a broader metaphyseal construct that incorporates bone grafting to assist with healing.
Because of these concerns and factors, we adapted our technique to create an individual-specific pedestal with allograft femoral head that can be anatomically matched to each patient. This provides a strut to reduce the head and tuberosity fragments but still limits the amount of allograft bone needed to seat into the existing canal. The geometry of the allograft can also be customized to the fracture, with most 3- and 4-part fractures needing a trapezoidal strut that resembles the metaphyseal portion of a fracture-specific shoulder arthroplasty implant.
We have used this technique for comminuted 3- and 4-part fractures of the proximal humerus in 14 cases with at least 2-year follow-up and in several more cases that have not reached 2-year follow-up. All cases have gone on to radiographic union; none have had to be revised either with revision ORIF or to an arthroplasty. Formal measurements of final postoperative range of motion have not been tabulated in all cases, as some cases have been lost to follow-up after radiographic union was achieved. Medium- and long-term results are not yet available, but no short-term complications have been noted.
Disadvantages of this technique are that, while an individualized graft is created, proper shaping still takes time, and a moderate amount of the femoral head is not used. However, we have found that, if a graft is inadvertently undersized, there is still ample femoral head remaining to create another sized graft. Other disadvantages are the added cost and the (rare) risk of disease transmission, which come with use of any allograft, but the technique is used instead of another type of allograft, so these disadvantages are largely equivalent. At our hospital, differences in cost and availability between femoral head or fibular allografts are negligible.
This procedure, which is easily performed in a short amount of time, allows a stable base of bone graft to be used as an aid in the anatomical reduction of proximal humerus fractures, without the need for reaming and preparation of the medullary canal and without further increasing the difficulty associated with a future revision procedure.
1. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-249.
2. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
3. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg. 2000;9(5):423-426.
4. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elbow Surg. 2006;15(2):239-243.
5. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681.
6. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741-748.
7. Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma. 2013;27(7):399-404.
8. Ong CC, Kwon YW, Walsh M, Davidovitch R, Zuckerman JD, Egol KA. Outcomes of open reduction and internal fixation of proximal humerus fractures managed with locking plates. Am J Orthop. 2012;41(9):407-412.
9. Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012;21(12):1787-1795.
10. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res. 1982;(167):255-259.
11. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212-215.
12. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300-3306.
13. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195-200.
14. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942.
15. Little MT, Berkes MB, Schottel PC, et al. The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma. 2014;28(6):338-347.
16. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech. 2010;25(7):642-646.
17. Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg. 2012;21(7):894-901.
18. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542-549.
1. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-249.
2. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
3. Liew AS, Johnson JA, Patterson SD, King GJ, Chess DG. Effect of screw placement on fixation in the humeral head. J Shoulder Elbow Surg. 2000;9(5):423-426.
4. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures. J Shoulder Elbow Surg. 2006;15(2):239-243.
5. Agudelo J, Schurmann M, Stahel P, et al. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21(10):676-681.
6. Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012;21(6):741-748.
7. Gradl G, Knobe M, Stoffel M, Prescher A, Dirrichs T, Pape HC. Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma. 2013;27(7):399-404.
8. Ong CC, Kwon YW, Walsh M, Davidovitch R, Zuckerman JD, Egol KA. Outcomes of open reduction and internal fixation of proximal humerus fractures managed with locking plates. Am J Orthop. 2012;41(9):407-412.
9. Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg. 2012;21(12):1787-1795.
10. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin Orthop Relat Res. 1982;(167):255-259.
11. Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212-215.
12. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300-3306.
13. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195-200.
14. Matassi F, Angeloni R, Carulli C, et al. Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury. 2012;43(11):1939-1942.
15. Little MT, Berkes MB, Schottel PC, et al. The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation. J Orthop Trauma. 2014;28(6):338-347.
16. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech. 2010;25(7):642-646.
17. Chow RM, Begum F, Beaupre LA, Carey JP, Adeeb S, Bouliane MJ. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Shoulder Elbow Surg. 2012;21(7):894-901.
18. Jost B, Spross C, Grehn H, Gerber C. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg. 2013;22(4):542-549.
