Thursday, January 23, 2014

Proximal humeral malunion - treatment with arthroplasty

Anatomic shoulder arthroplasty for treatment of proximal humerus malunions

Post-traumatic arthritis often presents a major challenge at shoulder arthroplasty.

These authors report the results they obtained in humeral malunion cases using  hemiarthroplasty in 45 and total shoulder arthroplasty in 50 patients. 

These procedures were often complex and on occasion required unusual positioning of the prosthesis and osteotomy and repositioning of the tuberosities in 37 cases. Rotator cuff repair was performed in 16. Other steps included removal of fixation in 18, acromioplasty in 11, biceps tenodesis in 6, trimming of greater tuberosity in 5, glenoidplasty in 4, humeral diaphyseal osteotomy in 1, posterior capsule plication in 1, and lengthening of pectoralis major in 1.

Overall, range of motion and comfort were improved. 31 shoulders had followup x-rays. Tuberosity osteotomies were healed in 20 cases.  Sixteen complications required 10 reoperations, including 6 of 9 patients with severe postoperative instability (which was often associated with rotator cuff and shoulder capsule injury). A postoperative brachial plexopathy developed in 1 patient, and hematomas developed in 2 patients. Heterotopic ossification developed in 1 patient. A deep infection developed in 1 patient. Subsequent periprosthetic humeral fractures developed in 2 patients.

Comment: these procedures are obviously not to be undertaken lightly by either the surgeon or the patient. While these authors were quite successful in obtaining tuberosity osteotomy healing, this can be a problem because of (1) retraction of the cuff muscles, (2) limited 'landing site' for the repositioned tuberosity, and (3) problems in protecting the osteotomy during healing.

To learn more about shoulder arthritis and what can be done about it, see the Shoulder Arthritis Book.

To learn more about the rotator cuff, see the Rotator Cuff Book

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