Başarısız İç Fiksasyon Sonrası Proksimal Humerus Kırıklarının Yönetiminde Ters Omuz Artroplastisinin Sonuçları

Öz

Arka Plan: Bu çalışma, başarısız iç fiksasyon nedeniyle revizyon cerrahisi gereken proksimal humerus kırığı hastalarında ters omuz artroplastisinin (RSA) klinik ve fonksiyonel sonuçlarını değerlendirmeyi amaçlamaktadır. Kırık tipi ve revizyon zamanlamasının ameliyat sonrası ağrı, eklem hareket açıklığı ve fonksiyonel skorlar üzerindeki etkisi de incelenmiştir. Yöntemler: 2017 ile 2020 yılları arasında başarısız iç fiksasyon sonrası RSA uygulanan hastalar üzerinde retrospektif bir analiz gerçekleştirilmiştir. Ameliyat sırasında onarılamaz rotator manşet yırtığı tespit edilen hastalar çalışmaya dahil edilmiştir. Fonksiyonel sonuçlar, Amerikan Omuz ve Dirsek Cerrahları Derneği (ASES) skoru, Constant-Murley skoru, QuickDASH ve Görsel Analog Skalası (VAS) kullanılarak değerlendirilmiştir. Eklem hareket açıklığı (fleksiyon, abduksiyon, internal ve eksternal rotasyon) da incelenmiştir. İstatistiksel karşılaştırmalar kırık tipi (Neer Tip 3 ve Neer Tip 4) ve revizyon süresine göre yapılmıştır. Bulgular: Neer Tip 4 kırığı olan hastalar, Neer Tip 3 kırığı olanlara kıyasla belirgin şekilde daha kötü fonksiyonel sonuçlara ve daha yüksek ağrı seviyelerine sahipti. Neer Tip 4 hastalarında VAS skoru (3.2±1.8), Neer Tip 3 hastalarına göre (0.9±0.9) daha yüksekti. Constant-Murley skoru Neer Tip 4 hastalarında (50.7±10.4), Neer Tip 3 hastalarında ise (61.8±9.0) olarak bulundu. Daha uzun revizyon süresi, daha kötü fonksiyonel sonuçlar, artan ağrı ve azalan eklem hareket açıklığı ile ilişkiliydi. Fleksiyon (102.9±23.1° vs. 80.0±22.8°) ve abduksiyon (99.4±19.2° vs. 73.3±22.5°), Neer Tip 3 ve Neer Tip 4 kırıkları arasında belirgin farklılık gösterdi. Ancak, RSA ameliyat sonrası tatmin edici ağrı kontrolü sağladı (VAS 1.5±1.5) ve fonksiyonel skorları iyileştirdi (ASES Operasyon Kol Skoru 59.0±21.3). Sonuç: Ters omuz artroplastisi, başarısız iç fiksasyon sonrası proksimal humerus kırıklarının tedavisinde etkili bir kurtarma prosedürüdür, özellikle de onarılamaz rotator manşet yırtığı olan hastalar için uygundur. Erken revizyon cerrahisi daha iyi fonksiyonel sonuçlarla ilişkilidir, gecikmiş revizyon ise artan ağrı ve azalmış omuz hareketliliğine yol açabilir.

Anahtar Kelimeler

• Ters omuz artroplastisi
• proksimal humerus kırıkları
• başarısız iç fiksasyon
• fonksiyonel sonuçlar
• revizyon cerrahisi

Outcomes of Reverse Shoulder Arthroplasty in the Management of Proximal Humerus Fractures Following Failed Internal Fixation

Abstract

Aim: This research aims to assess the clinical and functional outcomes of reverse shoulder arthroplasty (RSA) in patients with proximal humerus fractures who underwent revision surgery following unsuccessful internal fixation. The influence of fracture classification and the timing of revision surgery on postoperative pain, range of motion (ROM), and functional outcomes was also evaluated. Material and Method: A retrospective analysis was performed on patients aged 65 years or older who sustained fractures due to low-energy trauma, such as simple falls, and underwent RSA due to failed internal fixation of proximal humerus fractures between 2017 and 2020. Patients with intraoperatively identified irreparable rotator cuff tears were included in the study.Functional outcomes were measured using the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, the Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH), and Visual Analog Scale (VAS). Additionally, ROM, including flexion, abduction, internal rotation, and external rotation, was assessed. Statistical comparisons were conducted based on fracture classification (Neer Type 3 vs. Neer Type 4) and the interval between the initial fixation and revision surgery. Results: Patients with Neer Type 4 fractures had poorer functional outcomes and higher pain levels than those with Neer Type 3 fractures. The VAS score was higher (3.2±1.8 vs. 0.9±0.9), and the Constant-Murley score was lower (50.7±10.4 vs. 61.8±9.0) in Neer Type 4 patients. Delayed revision surgery led to greater functional decline, increased pain, and restricted motion. Flexion (102.9±23.1°) and abduction (99.4±19.2°) were better preserved in Neer Type 3 fractures than in Neer Type 4 (80.0±22.8° and 73.3±22.5°). However, RSA effectively reduced postoperative pain (VAS 1.5±1.5) and improved functional scores (ASES 59.0±21.3). Conclusion: RSA serves as a reliable reconstructive option for managing complications arising from unsuccessful surgical stabilization of proximal humerus fractures, especially in cases where the rotator cuff damage is beyond repair. Early revision surgery is linked to superior functional recovery, whereas delayed intervention may result in heightened pain and restricted shoulder movement.

Keywords

• Reverse shoulder arthroplasty
• proximal humerus fractures
• failed ınternal fixation
• functional outcomes
• revision surgery

Kaynakça

1. Jacobs AN, Umlauf JA, Kniss JR. Proximal humerus fracture following arthroscopic biceps tenodesis. J Orthop Sports Phys Ther. 2020;50:649.
2. Koeppe J, Stolberg-Stolberg J, Fischhuber K, et al. The incidence of proximal humerus fracture-an analysis of insurance data. Dtsch Arztebl Int. 2023;120:555-6.
3. Rudran B, Little C, Duff A, Poon H, Tang Q. Proximal humerus fractures: anatomy, diagnosis and management. Br J Hosp Med (Lond). 2022;83:1-10.
4. Marigi EM, Bartels DW, Aibinder WR, Cofield RH, Sperling JW, Sanchez-Sotelo J, et al. Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes. JSES Int. 2023;7:239-46.
5. Chawla H, Gamradt S. Reverse total shoulder arthroplasty: technique, decision-making and exposure tips. Curr Rev Musculoskelet Med. 2020;13:180-5.
6. Luster TG, Dean RS, Trasolini NA, et al. Predictive factors influencing internal rotation following reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2024;33:1200-8.
7. Galvin JW, Kim R, Ment A, et al. Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022;31:e534-44.
8. Perritt S, Roberts M. Flexural-slip structures in the bushveld complex, South Africa?. Journal of Structural Geology. 2007;29:1422.

9. Brorson S, Rasmussen JV, Olsen BS, et al. Reverse shoulder arthroplasty in acute fractures of the proximal humerus: a systematic review. Int J Shoulder Surg. 2013;7:70-8.
10. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52:1077-89.
11. Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg. 2008;17:42-54.
12. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;442:87-92.
13. García-Fernández C, Lopiz Y, Rizo B, et al. Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures. Injury. 2018;49:S22-6.
14. Dezfuli B, King JJ, Farmer KW, et al. Outcomes of reverse total shoulder arthroplasty as primary versus revision procedure for proximal humerus fractures. J Shoulder Elbow Surg. 2016;25:1133-7.
15. Savin DD, Zamfirova I, Iannotti J, et al. Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly. Int Orthop. 2016;40:1919-25.
16. Familiari F, Rojas J, Nedim Doral M, et al. Reverse total shoulder arthroplasty. EFORT Open Rev. 2018;3:58-69.
17. Patel DN, Young B, Onyekwelu I, et al. Reverse total shoulder arthroplasty for failed shoulder arthroplasty. J Shoulder Elbow Surg. 2012;21:1478-83.
18. Juhan T, Stone M, Jalali O, et al. Irreparable rotator cuff tears: current treatment options. Orthop Rev (Pavia). 2019;11:8146.
19. Farshad M, Gerber C. Reverse total shoulder arthroplasty-from the most to the least common complication. Int Orthop. 2010;34:1075-82.
20. Kristensen MR, Rasmussen JV, Elmengaard B, et al. High risk for revision after shoulder arthroplasty for failed osteosynthesis of proximal humeral fractures. Acta Orthop. 2018;89:345-50.
21. Obert L, Saadnia R, Tournier C, et al. Four-part fractures treated with a reversed total shoulder prosthesis: Prospective and retrospective multicenter study. Results and complications. Orthop Traumatol Surg Res. 2016;102:279-85.
22. Grubhofer F, Wieser K, Meyer DC, et al. Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly. J Shoulder Elbow Surg. 2016;25:1690-8.
23. Grubhofer F, Wieser K, Meyer DC, et al. Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus. J Shoulder Elbow Surg. 2017;26:92-100.
24. Cicak N, Klobucar H, Medancic N. Reverse shoulder arthroplasty in acute fractures provides better results than in revision procedures for fracture sequelae. Int Orthop. 2015;39:343-8.
25. Shannon SF, Wagner ER, Houdek MT, et al. Reverse shoulder arthroplasty for proximal humeral fractures: outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis. J Shoulder Elbow Surg. 2016;25:1655-60.
26. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987:160-4.
27. Wright JO, Ho A, Kalma J, et al. Uncemented reverse total shoulder arthroplasty as initial treatment for comminuted proximal humerus fractures. J Orthop Trauma. 2019;33:e263-9.
28. Sebastia-Forcada E, Lizaur-Utrilla A, Cebrian-Gomez R, et al. Outcomes of reverse total shoulder arthroplasty for proximal humeral fractures: primary arthroplasty versus secondary arthroplasty after failed proximal humeral locking plate fixation. J Orthop Trauma. 2017;31:e236-40.
29. Boileau P, Seeto BL, Clowez G, et al. SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae. J Shoulder Elbow Surg. 2020;29:2446-58.
30. Wolfensperger F, Grüninger P, Dietrich M, et al. Reverse shoulder arthroplasty for complex fractures of the proximal humerus in elderly patients: impact on the level of independency, early function, and pain medication. J Shoulder Elbow Surg. 2017;26:1462-8.
31. Pastor MF, Kieckbusch M, Kaufmann M, et al. Reverse shoulder arthroplasty for fracture sequelae: Clinical outcome and prognostic factors. J Orthop Sci. 2019;24:237-42.
32. Nielsen KP, Amundsen A, Olsen BS, Rasmussen JV. Good long-term patient-reported outcome after shoulder arthroplasty for cuff tear arthropathy. JSES Int. 2022;6:40-3.
33. Anakwenze OA, Zoller S, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review. J Shoulder Elbow Surg. 2014;23:e73-80.