Relazione Borsa di Studio Dott. Seghezzo


V. Seghezzo1,3
T. Mangano, MD2
G. Caione, MD2
M. Rossoni, MD2
D. Chiapale, MD1
N. Ivaldo, MD2
M. Giovale, MD2
1Department of Orthopaedics and Traumatology, Hospital S. Paolo, Savona, Italy
2GSL - Gruppo Sanitario Ligure, Shoulder Surgery Unit, Hospital S.M. di Misericordia, Albenga,
3Corresponding author:
Vittorio Seghezzo, MD
Ospedale S. Paolo
Via Genova 30, 17100 Savona (SV), Italy
Telephone: + 39 019 8404378
Fax: + 39 019 8404975
E-mail address:
Aim. In this work our goal was to define subjective and objective functional outcome, and
individual satisfaction after reverse shoulder arthroplasty (RSA) for humeral fracture in a cohort of
patients 70 or more years old at the time of surgery, with a mid-term follow-up.
Methods. From an original cohort of 33 patients treated with RSA between 2008 and 2012, 25
patients were evaluated from the clinical and radiographic site at an average 44 months follow-up
from surgery. Mean age at surgery was 77.8 (range 71-83). Constant-Murley (CM) and
standardized DASH scores were used for objective and subjective evaluation, respectively, while
standard X-rays were used for radiographic evaluation.
Results. Implant survival attested at 96% considering “revision for every reason” as the end-point.
CM and standardized DASH scores assessed at 57.4 and 69.8, respectively, while mean VAS for
pain attested at 0.48. Heterotopic bone formations and scapular notching were the most frequent
radiographic alterations, but no signs of implant loosening were reported. One patient underwent
revision surgery for periprosthetic humeral fracture and 4 more patients displayed minor transitory
postoperative complications.
Conclusion. RSA represent a useful and safe solution in case of complex humeral fracture in the
elder age patients, able to recovery a pain-free shoulder function for day-life activities in the large
majority of patients.
Key words: Proximal humeral fracture; Reverse shoulder arthroplasty; Elder patients;
Proximal humeral fractures account for 4-5% of all fractures but this proportion progressively
increases with the age of the studied population, reaching 10% in the elder people1,2. Nonoperative
treatment is able to ensure healing in approximately 80% of cases. Only the minority of these
fractures requires a surgical management, in relation to patient's functional requirements or to
increased fracture complexity3. In such cases, humeral head substitution represent the preferred
approach when open reduction and internal fixation (ORIF) are technically difficult or not possible,
or when the risk of subsequent avascular necrosis is high4.
Shoulder hemiarthroplasty has been considered for years a standard treatment in case of complex
proximal humeral fractures. However, a consistent variability in clinical outcomes represents the
rule when using such device, due to patient-, fracture-, surgeon- and technique-related factors5-7.
Initially designed for low-demand, elderly patients with rotator cuff tear-related arthropathy, reverse
shoulder arthroplasty (RSA) relies less on a functioning rotator cuff and/or tuberosity healing than
hemiarthroplasty does8. Due to these features and to encouraging published results, RSA indications
have widened in the last decade to include complex proximal humeral fractures, especially in the
elder patients, despite some doubts still exist in relation to clinical outcome and post-operative
complications9,10. Furthermore, most of published works included a wide range of patient's age,
eventually confounding the conclusions that could be drawn relatively to the elder people only, the
ideal recipient of such treatment11-16.
The aim of this work was to define subjective and objective functional outcome, and individual
satisfaction after RSA for humeral fracture in a cohort of patients 70 or more years old at the time
of surgery, with a mid-term follow-up.
Patients and methods
Between 2008 and 2012, 33 patients were managed in two different institutions, a university
hospital and a district hospital, for complex proximal humeral fractures and received a reverse
shoulder arthroplasty. The mean age at the time of surgery in this series was 78.5 years. X-ray
examination was immediately conducted in the Emergency Department. The patients were studied
before surgery with computed tomography (CT) and three-dimensional reconstruction in order to
achieve better characterization of fracture pattern and fragments displacement. Fracture pattern and
indication for RSA were assessed by the two senior authors (M.G. and N.I.).
A written informed consent about future use of registered personal data for scientific purposes was
obtained from all the patients before surgery. A further informed consent was obtained from the
subjects being involved in the study. The Regional Ethical Committee was made aware of this work
and of the submission of our data for publication, and gave formal approval (registration number
127/2014). The study has been performed in accordance with the ethical standards as laid down in
the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
The index procedure was performed within 15 days from trauma (range 2–15 days), always after
anaesthesiologic and medical evaluation for eligibility to surgery. After surgery, patients were
routinely evaluated at 3, 6, 12 months, and annually thereafter. Furthermore, patients were
evaluated from the functional and radiographic site in the setting of the present study, at an average
of 44 months from surgery (range 36-72 months). At the time of the study, three patients had died
for unrelated causes, three were lost, two were unwilling to participate in the study. Then we were
able to include in this retrospective study a total of 25 patients. In this series, 4 were men and 21
women, and mean age at the time of surgery was 77.8 (range 71–83). The right arm was involved in
14 cases and the left arm in 11. Referring to the clinical records and according to the Neer
classification, indications for surgery were 3-part fracture–dislocation in five patients, 4-part
fracture in 14 patients, 4-part fracture–dislocation in six patients. Twenty-two patients (22
shoulders) received a SMR reverse total shoulder arthroplasty (LIMA-LTO, San Daniele, Italy),
while 3 patients (3 shoulders) received a Delta Xtend implant (DePuy- Synthes, Warsaw, IL, USA).
The prosthetic implant was cemented in all but 6 cases. Patients were operated on by two senior
surgeons with years of experience in the field of shoulder surgery (N.I., M.G.) and were managed
with standard technique.
A second generation cephalosporin was used for antibiotic prophylaxis, administered before surgery
and continued for 2 days postoperatively. Antithromboembolic prophylaxis was constantly used by
mean of a low-molecular weight heparin. In the beach-chair position, a deltopectoral incision was
made, the cephalic vein exposed and lateralized or dissected and the conjoined tendon medialized.
After identification of the long head of the biceps and its groove, every fracture fragment was
characterized. The greater and the lesser tuberosities were identified, separated and distracted using
a non-absorbable 2/0 Ethibond (Ethicon Inc., USA), then the cephalic fragment was removed. The
long head of the biceps was always tenotomized. The glenoid metal-back was placed in line with
(or slightly overhanging) the inferior margin of the glenoid, with a 10°–15° inferior tilt in order to
minimize notching17. After preparing the humeral canal, two or three holes were drilled near its
prox- imal margin and a 2/0 Ethibond inserted, for successive vertical stabilization between the
shaft and the tuberosities. Complete tuberosities reconstruction was finally possible in 2 patients,
while in 6 cases only the greater tuberosity was reconstructed. After trials, the definitive prosthesis
was implanted and the tuberosities fixed to the humeral shaft using the previously passed sutures. A
suction drain was always positioned and removed 2 days after surgery. The operated shoulders were
immobilized with a sling in adduction and internal rotation for 4 weeks. Active movements at the
elbow were allowed starting at 14 days after surgery. Passive-assisted exercises for shoulder range
of motion begun 4 weeks after surgery and pendulum exercises as well.
In the setting of the present study, clinical outcomes were assessed at follow-up visits using the
Constant-Murley scoring system18 (CM score; 0–100) without correction for sex and age. A
goniometer was used to measure ROM. Strength was measured as resisted elevation against a
spring balance dynamometer (max 25 pounds). Subjective functional assessment was studied with
the Disability of the arm, shoulder and hand (DASH) outcome measure19. We applied the
standardisation as suggested by Allom et al.20 in order to convert the DASH score into a scale of 0
to 100 (std DASH score), where 100 is representative of a normal shoulder. Subjective satisfaction
was studied through patients self-assessing into one of three groups: satisfied, moderately satisfied
and unsatisfied with respect to treatment outcome.
Anteroposterior, lateral transthoracic and axillary radiographs of the shoulders were used for
radiological assessment. Radiographs were grossly studied for the presence of heterotopic bone
formation, signs of fracture or dislocation, scapular notching and signs of prosthetic loosening.
We reported categorical variables as frequencies (percent) and continuous variables as means and standard
deviations (SD). For comparing continuous variables we used the Mann–Whitney U test were used. A p
value of 0.05 was considered to be statistically significant. For box plot data organization we referred to the
BoxPlotR software available at http://boxplot.tyerslab.com21.
At an average of 44 months from surgery (range 36-72 months) we evaluated 25 patients treated
with RSA for complex humeral fractures. Mean age at surgery was 77.8 (range 71–83). No
intraoperative complications were reported. During the follow up period, one patient underwent
revision surgery for periprosthetic fracture due to accidental fall. With “revision for every reason”
as the end-point, mean survival of the implants attested at 96%. Postoperative complications were
observed in four more patients. Two patients reported transient brachial plexus palsy as associated
injury at the time of trauma, which completely remitted at 2 and 7 months following surgery,
respectively. Two patients suffered from minor episodic instability with subluxation events few
months after surgery, resolved with physiotherapy in both cases.
In this series mean CM and stdDASH scores attested at 57.4 (range 38-85) and 69.8 (range 48-
87.5), respectively; mean VAS attested at 0.48 (range 0-3). Boxplot distribution of these values is
reported in figure 1. Two patients complained mild episodic pain during activities of daily living,
while 2 patients reported mild to moderate pain. When present, pain was poorly localized (2 cases)
or referred to the deltoid muscle origin (1 case) or insertion (1 cases). Active range of motion was
recorded at last follow-up visit and is reported in table 1. Patients were completely satisfied in 14
cases, moderately satisfied in 8, and not satisfied in 3.
At the radiographic analysis, no signs of implant loosening were evident. Glenoid periprosthetic
osteopenia was evident in 3 shoulders, without subsidence of the prosthetic component.
Heterotopic bone formations without continuity with the scapular neck were present in 7 shoulders.
Scapular spurs were present in two cases. Scapular notching was present in 4 shoulders, never
extending beyond the inferior screw (i.e. Sirveaux-Nérot grade II). None of the upon mentioned
findings was associated with clinical signs and symptoms suggestive for prosthetic loosening, pain
or lower function (p>0.5).
Since the work of professor Neer, shoulder hemiarthroplasty has represented the gold standard
solution in case of complex proximal humeral fracture, when open reduction and internal fixation
were not possible or contraindicated for high risk of humeral head avascular necrosis22,23. Several
works in the literature, however, have highlighted the important variability in clinical outcomes,
due to patient-, fracture-, surgeon- and technique-related factors24-31. Particularly in the elder
people, described clinical results are often poor, due to higher risk of complications (e.g. secondary
rotator cuff failure) and not adequate compliance to the rehabilitation program26,30,31.
In the last decade, RSA indications have progressively widened to include complex humeral
fracture management. Due to design and biomechanical features, functional results with this kind of
prosthesis relies less on a functioning rotator cuff and/or tuberosity healing than hemiarthroplasty
does8. Despite a consistent risk of peri- and postoperative complications9,10, RSA offers a useful
solution for complex humeral fractures, especially in case of elder patients without high functional
requests. Nevertheless, most of published series encompass a wide range of patient's age, possibly
biasing the final results and not allowing a final definition of clinical and radiologic mean outcome
in the elder patients, and complication rate as well11-16.
In our retrospective work, we reviewed a series of 25 patients treated with RSA for complex
proximal humeral fracture, with age at surgery ranging from 71 to 83 years. With a mean follow-up
of 44 months from surgery, all of the implants were in situ at the time of this study. Only one
patient needed revision for periprosthetic humeral fracture in the postoperative period, while four
patients suffered from transitory minor complications (i.e. fracture-associated brachial plexus palsy
and postoperative minor instability). In this series, mean CM and standardized DASH scores
assessed at 57.4 and 69.8, respectively, comparing well with results published elsewhere13-16.
Episodic pain was present in a minority of patients, never limiting activities of daily living, and
88% of patients resulted satisfied or moderately satisfied with the final outcome. Main radiographic
alterations were represented in this series by scapular notching (4 cases) and heterotopic bone
formations (9 cases), and were not associated with lower functional results or risk of implant
Some authors have suggested that also in case of RSA implantation the presence of anatomically
healed tuberosities is a beneficial factor for function recovery11,12. In a recent work from Gallinet
and coworkers32, the authors found better functional results in patients in whom the tuberosities had
been successfully repaired after RSA implantation. Despite tuberosities were repaired when
possible, limited number in our series prevented us a reliable statistical analysis comparing groups
of patients who underwent tuberosities reconstruction or not. Furthermore, clinical outcomes did
not strikingly differ between these two groups of patients (fig. 2 and 3). Nevertheless, global results
we reported in term of function recovery are similar to those published by other authors, showing
acceptable final functional results in the mid-term follow-up from surgery, with limited variability
between patients.
This work has several shortcomings. First of all, it is a retrospective study with limited number of
involved patients. Secondly, there is not a control group of patients treated with different modalities
for the same indication. Finally, all the operations were managed by surgeons with years of specific
experience in shoulder surgery. Despite the above mentioned limitations, a fine analysis of factors
involved in outcome variability was not our initial goal. With this work, we intended to define
general subjective and objective functional outcomes, individual satisfaction and complication rate
in a series of patients treated with RSA for complex humeral fractures, with age at surgery of
seventy or more years. Proximal humeral fractures often occur in the group of elder and lowdemand
patients, who can have multiple comorbidities and reduced requirements with regard to
shoulder function. In this population group, the primary goal of treatment is to achieve a pain-free
shoulder mobility that provides acceptable function for activities of daily living. In line with other
authors, we can conclude that RSA is a useful an safe solution in case of complex proximal humeral
fracture in the elder age, able to offer in the large majority of patients a functional recovery for daylife
needing, with acceptable complication rate. Despite a conclusive demonstration is still lacking,
emerging evidences seem to warm the idea that a new paradigm in treating this kind of pathology in
this kind of patient is coming out and indications for hemiarthroplasty are progressively being
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FIGURE 1. Box-plot distribution of Constant-Murley (CM), standardized DASH (stdDASH) and VAS
for pain in the evaluated series.
FIGURE 2. 73 years old male patient with 4-part fracture-dislocation of the proximal humerus. a)
Preoperative X-rays and b) 3D-CT scan. c) X-rays control and d-f) clinical evaluation 4,5 years
from surgery.
FIGURE 3. 77 years old female patient with 4-part fracture-dislocation of the proximal humerus.
a) Preoperative X-rays and b) 3D-CT scan. c) X-rays control 6,2 years from surgery. d)
Intraoperative view of partial subscapularis reinsertion. e-g) Clinical evaluation 6,2 years from
TABLE 1. Active range of motion mean values reported in the evaluated series.

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