The document discusses the complexities of proximal humeral fractures and various surgical approaches for their treatment, including techniques for shoulder arthroplasty. It highlights the importance of correct surgical methods and the impact of pre-existing conditions on patient outcomes. The summary of findings compares the effectiveness of open reduction and internal fixation (ORIF) versus hemiarthroplasty, emphasizing the significance of tuberosity reconstruction for successful functional recovery.

1. JOURNAL CLUB
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2.  William Osler first introduced the concept of
‘Journal club’ in 1875
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3. 3

4. David Dines-
 Ex President of the American
Shoulder and Elbow Society
 Biomet Biomodular Total
Shoulder System
Josua Dines James E. Voos
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5.  Proximal humeral fractures account for 4% to
5% of all fractures
Complex Fractures
? ORIF
? Hemi
? RSA
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6.  Concomitant injuries
 Preinjury shoulder function
? Previous fracture
? Previous rotator cuff deficiency
? Severe osteoporosis
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7.  AP
 Transscapular Y View
 Axillary view
 CT :Extensive comminution,
displaced #
 Full length view C/L
humerus - Template
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8. 8

9.  NEER’S (>1cm displacement, >45˚ angulation )
 AO
 HERTEL’S
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H
G
S
L

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11. SSuurrggiiccaall tteecchhnniiqquuee::
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12. Delto pectoral incision
Different Fibre orientation
Cephalic vein laterally
Axillary fold
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13. Keep Deltoid origin & insertion intact
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14. Incise fascia over biceps tendon
Identify the LHB
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15. Identify long head of biceps
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16. Separate & secure the tuberosities.
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17. Secure sutures in tendon bone interface
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18. Excision of fractured Humeral head
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19. Visualise the Glenoid
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20. Humeral canal is prepared by
sequential reaming
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21.  Anterolateral & posterolateral
drill-holes
 1 to 1.5 cm distal to the fracture
 Sutures are placed through these
holes prior to cementing
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22. Height of the component
 pre op Templating
Intramedullary device
Measurements on device
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24. 24

25. Effect of Incorrect Version
Too Anteverted Too Retroverted
Tuberosity healing compromised
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26. Closed reduction
with trial head
component.
The head should translate 50%
anteriorly, posteriorly, &
inferiorly on the glenoid
surface.
160˚ of forward elevation and
stable internal & external
rotation of the arm.
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27. SSuucccceessss ooff ssuurrggeerryy ==
TTuubbeerroossiittyy rreeccoonnssttrruuccttiioonn
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28. Bone grafting prior
to tuberosity fixation
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29. The final humeral head component is placed after the
sutures have been passed, and the tuberosity
reconstruction commences.
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30. The greater tuberosity is secured to the shaft & the
implant first, and this is followed by
fixation of the lesser tuberosity.
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31. Vertical, Horizontal & Figure of eight sutures
fix the tuberosities in position.
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32.  Based security of the reconstruction.
 0 to 6 weeks : Only Passive
 > 6 wks : Active assisted exercises
 8 to 12 weeks : Strengthening exercises
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33. Component malposition
Rotatorcuff failure
Periprosthetic fracture
Heterotopic ossification
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34.  Good pain relief, but varying outcomes with
regards to
function,
motion &
strength.
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35. Bastian and Hertel : ORIF vs Hemi
similar ffuunnccttiioonnaall rreessuullttss && ppaattiieenntt ssaattiissffaaccttiioonn.
ORIF with preservation of the humeral head should
be considered when an adequate reduction and
stable conditions for revascularization can be
obtained.
Hemiarthroplasty is a viable alternative for
patients with osteopenic bone and/or a
comminuted fracture.
Bastian JD, Hertel R. Osteosynthesis and hemiarthroplasty
of fractures of the proximal humerus:
outcomes in a consecutive case series. J Shoulder
Elbow Surg. 2009;18:216-9
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36. Krishnan et al. : using ‘Gothic arch’ technique
reported 88% of the tuberosities healed
anatomically. The mmeeaann aaccttiivvee aanntteerriioorr eelleevvaattiioonn
wwaass 112299˚,, aanndd ppaaiinn ssccoorreess aavveerraaggeedd 11..22 ppooiinnttss oonn
aa 1100--ppooiinntt ssccaallee.
Krishnan SG, Bennion PW, Reineck JR, Burkhead
WZ. Hemiarthroplasty for proximal humeral fracture:
restoration of the Gothic arch. Orthop Clin North Am.
2008;39:441-50,
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37. Boileau et al. described the ‘‘‘‘uunnhhaappppyy ttrriiaadd,,’’’’ in
which a prosthesis has excessive height and
retroversion and the greater tuberosity is
positioned too low --> poor functional results,
persistent pain & stiffness.
Boileau P, Walch G, Krishnan SG. Tuberosity
osteosynthesis and hemiarthroplasty for four-part
fractures of the proximal humerus. Tech Shoulder
Elbow Surg. 2000;1:96-109.
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38. Accuuttee reconstruction (less than four weeks
after the injury) results in bbeetttteerr functional
outcomes because of the ease of tuberosity
reconstruction
Dines DM, Warren RF. Modular shoulder
hemiarthroplasty for acute fractures. Surgical
considerations. Clin Orthop Relat Res. 1994;307:
18-26.
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39. Bufquin et al. In RRSSA ssaattiissffaaccttoorryy mmoobbiilliittyy wwaass
oobbttaaiinneedd ddeessppiittee ffrreeqquueenntt mmiiggrraattiioonn ooff tthhee
ttuubbeerroossiittiieess, and they cautioned that an
assessment of long-term results is required.
Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder
arthroplasty for the treatment of three- and four-part fractures of
the proximal humerus in the elderly: a prospective review of 43
cases with a short-term follow-up. J Bone Joint Surg Br.
2007;89:516-20.
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40. DDeesscceennddiinngg oorrddeerr ooff CClliinniiccaall ssuucccceessss:
(1) Hemi in a patient with reconstructible tuberosities,
(2) RSA in a patient with reconstructible tuberosities,
(3) RSA in a patient without reconstructible tuberosities,
(4) Hemi in a patient without reconstructible tuberosities.
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41.  Newer techniques to improve functional
outcomes.
 Long term multicentric randomised comparative
study between RSA & Hemiarthroplasty.
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42. 42 THANK YOU