Journal of Orthopaedic Surgery 2011;19(2):194-9

Hemiarthroplasty for comminuted proximal

humeral fractures
Ashish Babhulkar,1 Ashok K Shyam,1,2 Parag K Sancheti,1 Koshish Shah,1 Steve Rocha1
1
Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India
2
Indian Orthopedic Research Group, Mumbai, Maharashtra, India

p=0.008] and in patients operated after 7 days (n=6)

ABSTRACT
Purpose. To evaluate early functional outcomes of
hemiarthroplasty for 3- or 4-part proximal humeral
fractures.
Methods. 16 men and 11 women aged 27 to 83
(mean, 56) years underwent hemiarthroplasty for
comminuted 3-part (n=13) or 4-part (n=14) proximal
humeral fractures. All the patients reported normal
shoulder function prior to injury. The range of
shoulder motion and muscle power were evaluated,
as were subjective pain and satisfaction (using the
UCLA scoring system).
Results. At the final follow-up, the mean maximum
abduction was 111º (SD, 47º; range, 30º–180º), and the
mean maximum forward flexion was 143º (SD, 41º;
range, 45º–180º). All patients had radiographic union
of the tuberosities. The mean UCLA score was 28;
21 patients attained good-to-excellent scores (≥27),
whereas 6 attained lower (fair-to-poor) scores. The
mean UCLA score was higher in patients aged <60
(n=13) than those who were older (n=14) [30 vs. 26,
than those operated before 7 days (n=21) [32 vs. 27,
p=0.02], but did not differ significantly in terms of
gender and fracture type and side. Patient age and
gender, fracture type, and injury-to-surgery interval
did not have a significant impact on maximum
forward flexion and abduction.
Conclusion. Early functional outcomes of
hemiarthroplasty for comminuted proximal humeral
fractures is good in medically fit and cooperative
patients.
Key words: pain measurement; range of motion,
articular; shoulder fractures; treatment outcome
INTRODUCTION
The proximal humerus is involved in 4 to 5%
of all fractures; 11% of these entail 3- or 4-part
fragments.1 The interval from injury to surgery is
important for treatment success,2 as is the decision
to perform anatomic reconstruction with fixation
or hemiarthroplasty.2 For comminuted fractures,

Address correspondence and reprint requests to: Dr Ashok K Shyam, Academic Research Division, Sancheti Institute of Orthopaedics
and Rehabilitation, 16 Shivaji Nagar, Pune 411 005, Maharashtra, India. E-mail: drashokshyam@yahoo.co.uk
Vol. 19 No. 2, August 2011 Hemiarthroplasty for comminuted proximal humeral fractures 195
conservative treatment usually yields poor results,
whereas osteosynthesis is often unfavourable in those
who are osteoporotic.1 Hemiarthroplasty for 3- and
4-part proximal humeral fractures achieves varying
results from excellent3.4 to suboptimal or poor.1,5–19
Improvement in surgical technique and the use of
modular prostheses has enabled better functional
outcomes.20–29 Restoration of humeral length and
correct positioning of the tuberosities are the keys
to success.5 Better results are usually achieved in
primary than secondary hemiarthroplasty,30–33 which
is the gold standard for nonviable or non-amenable
fractures.3 We evaluated early functional outcomes of
hemiarthroplasty for 3- or 4-part proximal humeral
fractures.
MATERIALS AND METHODS
Between January 2006 and December 2008, 16
men and 11 women aged 27 to 83 (mean, 56) years
underwent hemiarthroplasty for comminuted 3-part
(n=13) or 4-part (n=14) proximal humeral fractures
that were non-amenable by internal fixation. 12 of the
patients injured the right side. All patients reported
normal shoulder function prior to injury. Patients
with associated ipsilateral upper-limb fractures,
neurovascular injury, compound fractures, or similar
previous injury were excluded.
A modular prosthesis (Bigliani-Flatow, Zimmer)
was used. Its stem was 130-mm long for all patients;
22 received size-10 or -11 stems, and the remaining
5 received size-9 and -8 stems. Its humeral head
thickness was one size less or equal to the extracted
humeral head and included 46x18 mm (n=13), 46x15
mm (n=5), 40x18 mm (n=6), and 40x15 mm (n=3).
Surgeries were performed by a single surgeon via
a delto-pectoral approach. Detachment of the deltoid
(a) (b)
Figure 1 (a) Tuberosities are repaired with 2-0 Ethibond non-absorbable sutures and then (b) placed under tension after
fixation of the Biglani-Flatow prosthesis, (c) with watertight suturing of the surrounding soft tissues.
to improve exposure was not necessary. The fractured
lesser tuberosity was retracted medially to expose
the humeral head. When the lesser tuberosity was
not fractured, either a lesser trochanteric osteostomy
(preferred) or subscapular tenotomy was performed.
The long head of the biceps tendon was tenotomised at
its insertion at the superior glenoid tubercle and then
tenodised into the groove for the tendon of the long
head of the biceps. Thinning, attenuation, and minor
tears of the rotator cuff were commonly encountered.
After thorough medullary lavage, antibiotic
impregnated cement was delivered by a cement gun
in a retrograde fashion. The prosthesis was inserted,
and the tuberosities were placed under tension and
repaired with 2-0 Ethibond non-absorbable sutures.
The gap in the rotator cuff between the anterior edge
of the supraspinatus and the superior edge of the
subscapularis was closed with multiple interrupted
non-absorbable sutures (Fig. 1).
Postoperatively, a sling pouch was used. Gravity-
assisted pendulum exercises and passive motion
exercises were allowed on day 1. At week 3, assisted
forward elevation and supine external rotation and
full elbow range-of-motion exercises were allowed for
the next 6 weeks or longer (until adequate tuberosity
healing). At weeks 6 to 8, stretching and strengthening
of the shoulder with the help of a theraband was
allowed under supervision. Daily home exercises
were then prescribed for 6 to 10 weeks, and activities
of daily living (bathing, eating, and personal hygiene)
were allowed. Daily home exercises were encouraged
for at least 6 months, and preferably one year.
Patients were followed up at weeks 2 and 6,
months 3 and 6, and then half yearly thereafter. The
range of shoulder motion and muscle power were
evaluated, as were subjective pain and satisfaction
(using the UCLA scoring system).
The t-test was used to compare means of
(c)
196 A Babhulkar et al. Journal of Orthopaedic Surgery
continuous variables between categories. The non-
parametric Mann-Whitney U test was used to
compare the distribution of UCLA scores between
categories. The Fisher’s exact test was used to
compare the percentage distribution of UCLA scores
between categories. A p value of <0.05 was considered
statistically significant.
RESULTS
The mean injury-to-surgery interval was 6.7
(standard deviation [SD], 6; range, 2–21) days. The
mean duration of hospital stay was 7 (SD, 2.5; range,
5–14) days. The mean time to radiographic union
of the tuberosities was 7.3 (range, 6–15) weeks. The
mean duration of follow-up was 21.4 (range, 13–54)
months.
At the final follow-up, the mean maximum
abduction was 111º (SD, 47º; range, 30º–180º), and the
mean maximum forward flexion was 143º (SD, 41º;
range, 45º–180º). All patients achieved radiographic
union of the tuberosities, and 11 endured moderate
pain.
The mean UCLA score was 28; 21 attained
good-to-excellent scores (≥27), whereas 6 attained
lower (fair-to-poor) scores. Among the latter, one
had a good range of motion but was not satisfied
with his result; 4 were aged >70 years and adhered
poorly to the rehabilitation protocol; and one
developed rheumatoid arthritis that was treated
with corticosteroids. This patient had wasting of
the rotator cuff muscles and underwent prolonged
physiotherapy. He also endured severe superior
(a) (b)
Figure 2 (a) Pre- and (b) post-operative radiographs of a 45-year-old man: (c) at year 1, his humeral head migrates superiorly
owing to the weak rotator cuff; it returns to the anatomic position after 3 months of physiotherapy.
migration of the humeral head attributable to the
weak rotator cuff (Fig. 2).
The mean UCLA score was better in patients
aged <60 (n=13) than those who were older (n=14)
[30 vs. 26, p=0.008, non-parametric Mann-Whitney U
test] and in patients operated after 7 days (n=6) than
those operated before 7 days (n=21) [32 vs. 27, p=0.02,
non-parametric Mann-Whitney U test], but did not
differ significantly in terms of gender and fracture
type and side (Table). Patient age and gender, fracture
type, and injury-to-surgery interval did not have a
significant impact on maximum forward flexion and
abduction (Table).
One patient died from a colorectal carcinoma one
year later, after undergoing 3 surgeries and 12 cycles
of chemotherapy prior to shoulder hemiarthroplasty.
Another patient developed a haematoma around the
shoulder immediately after the operation owing to a
malfunctioning drain. The haematoma resolved after
conservative treatment. Functional recovery was
not delayed; the UCLA score was 27 at the 6-month
follow-up.
DISCUSSION
Hemiarthroplasty is the best treatment modality
for comminuted proximal humeral fractures.4,5 It
enables good pain relief, but functional limitation
may persist.5,19 Patient age, gender, injury-to-
surgery interval, rehabilitation time, and condition
of the rotator cuff affect functional outcome,25,34,35
as does anatomic union of the tuberosities and
rotator cuff.36–40 Better functional outcomes are
(c)
Vol. 19 No. 2, August 2011 Hemiarthroplasty for comminuted proximal humeral fractures 197

Table
Correlation of UCLA score and range of motion with patient age and gender, side of injury, fracture type, and injury-to-
surgery interval
Variable No. of Mean±SD p Value (non % of patients p Value Mean±SD p Value Mean±SD p Value
patients UCLA parametric (Fisher’s maximum (t test) maximum (t test)
score Mann- UCLA UCLA exact forward abduction
Whitney U score of score of test) flexion (degrees)
test) <27 ≥27 (degrees)
Age (years) 0.008 0.016 0.168 0.260
<60 13 30±2 0 100 134±35 122±39
≥60 14 26±6 43 57 113±44 101±52
Gender 0.54 0.49 0.424 0.708
Females 12 28±5 25 75 116±38 107±42
Males 15 29±5 20 80 129±43 114±51
Side of injury 0.22 0.124 - -
Left 15 27±5 27 73 - -
Right 12 30±5 17 83 - -
Fracture type 0.88 0.86 0.736 0.503
3 part 13 29±4 23 77 126±38 117±46
4 part 14 28±6 21 79 120±44 105±48
Injury-to-surgery 0.02 0.0001 0.105 0.06
interval (days)
≤7 21 27±5 29 71 116±40 102±46
>7 6 32±2 0 100 147±34 142±39

achieved following primary than secondary
hemiarthroplasties.31–33 Tension in the glenohumeral
muscles and ligaments is difficult to restore once soft
tissues are scarred following previous surgery. Soft-
tissue balance may be restored through permutations
and combinations of various modular prostheses,
which provide varying heights, widths, posterior
offsets, and versions of the humeral stem.41,42
Younger patients are more likely to have an
intact rotator cuff and/or good bone stock at the
tuberosity, leading to healthier abductor function of
the arm and better functional outcomes.14,16,22,26,28 In
our study, elderly patients could also benefit from
hemiarthroplasty, as their final range of shoulder
motion (maximum forward flexion and abduction)
did not differ significantly from younger patients. The
severity of the fracture has little impact on outcomes.39
Patients who were operated after 7 days from injury
had better functional score than those operated before
7 days. This may be due to fragile soft tissues in acute
condition. However, the sample size in the delayed
group was small (n=6), and further investigation is
needed to make this conclusion. In our study, patient
age and gender, fracture type, and injury-to-surgery
interval did not have a significant impact on the
range of shoulder motion. Early or late mobilisation
regimen also has no significant effect.35,43,44
Complications after humeral head replacement
include infections, wound problems, nerve injuries,
intra-operative fractures, instability, non-union
and migration of the tuberosities, rotator cuff tears,
component malposition and loosening, heterotopic
ossification, and stiffness.45
Limitations of our study included the lack of
a control group, the small sample size, and wide
age range of the patients. Radiological parameters
(humeral head offsets and elevation of the humeral
head) were not evaluated. Their role in functional
outcome is poorly understood.46 Longer follow-up is
needed to comment on implant loosening and wear.

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