Ocena funkcji stawu ramiennego po endoprotezoplastyce
połowiczej w wieloodłamowych złamaniach bliższego końca
kości ramiennej z uwzględnieniem rekonstrukcji stożka
rotatorów w modyfikacji własnej.
Rozprawa doktorska
Autor: Adam Kosim
Promotor: :prof. dr hab. med. Stanisław Pomianowski
Abstract
Comminuted fractures of the proximal humerus constitute a problem with regards to treatment. This is
due to difficulties in attaining permanent fracture reduction which is required for the initiation of
effective rehabilitation of the injured shoulder joint. Particularly useful in patients with poor bone
quality, one available method of treatment is glenohumeral arthroplasty. The main problem concerning
shoulder replacement surgery is reconstruction of the rotator cuff, the propelling force behind
movement of the shoulder joint. The position of the humerus tubercles, as important muscle attachment
sites, has a fundamental influence on the functioning of the shoulder joint. The constant search for
methods of obtaining strong and permanent rotator cuff repair techniques was the inspiration for a
thorough analysis of the results of glenohumeral arthroplasty using a modified humerus tubercle
fixation technique.
Aim
Since the introduction of glenohumeral arthroplasty to St. Anne's Trauma Surgery Provincial Hospital
in 2009, I have been implementing the same operative technique of humerus tubercle fixation with the
use of Dallos polyester bands, assuming that, on one hand, the surgical procedure should be maximally
simplified, and on the other, fixation of individual fracture parts should be as strong and permanent as
possible. The aim of the study was:

assessment of shoulder joint function after hemiarthrosplasty performed post-trauma in
comminuted fractures of the proximal humerus with the subsequent reconstruction of the rotator
cuff using a modified, personal technique

analysis of functional variables including age, gender, limb dominance, type of fracture (three,
four and four-part fractures with humeral head dislocation) as well as time lapse between injury
and surgery.

Comparison of results with the studies of other authors.
Materials and methods
The examination was carried out in the form of an observational study to which patients were included
upon commencement of surgery. Analysis of results was carried out a minimum of 6 months after each
surgical procedure. The following criteria were taken into account:

degree of flexion and abduction

ordinal scale assessment of external and internal rotation

DASH and Constant scale scores

level of pain using the numerical VAS scale

HTD length measured in millimeters

length of time to reach satisfactory results following the surgical procedure, as evaluated by
each individual patient.
56 people were qualified for the study, aged between 48 and 87 years, for whom the average age at the
time of injury was 69.5±10.5 years. Male subjects constituted 28.6% (n=16) of the 56 subjects qualified
for the study. All those examined had been operated at St. Anne's Trauma Surgery Provincial Hospital
in Warsaw (16/20 Barska St.), each procedure having been performed by the same surgeon – the author
of this study. The analysis concerns patients operated between 2009 and 2013.
Results
Nearly half (48.2%) of the patients reached a satisfactory status 6 months after surgery, 83.2% after 1
year, with 13.4% not reaching the satisfactory level upon completion of the observational period of 15
months. Gender and age were not observed to have an influence on estimating patient satisfaction,
however chances of acquiring satisfactory results grew by 1% with every year of a given patient's age.
In the elderly (patients over70 years of age), a satisfactory score 15 months after the procedure was
observed 5% more often when compared with younger patients. HTD values were observed to have a
strong correlation with chances of reaching an earlier patient satisfaction outcome. A 1 mm increase in
HTD distance correlated with a 5% smaller chance of patient satisfaction. Based on statistical analysis,
a border HTD value was established (10mm), the exceeding of which correlated with a significant drop
(39%) in early patient satisfaction rates. It was found that neither age nor time lapse between injury and
surgery were predictors of rotation, flexion, abduction as well as VAS, DASH and CS scales. HTD
distance, however, was significantly correlated to the above values: positively with DASH and VAS
and negatively with respect to external rotation, flexion and abduction angles. It was also noted that
HTD distance was considerably linked with surgical performance, with a 50% level of positive results
with respect to flexion, abduction, level of pain according to the Neer scale, as well as DASH and CS
scale results. In order to achieve at least a 50% level of positive (good) results with respect to flexion,
abduction, VAS scale pain level as well as CS scale results, it was shown that HTD distance should be
lower than, respectively, 10, 8, 8 and 5 mm; and as for positive results in the DASH scale – lower than
11 mm. It was, however, observed that even the smallest HTD measurements do not guarantee 50%
successful operative procedures with regards to full range of external rotation. Upon analyzing the
relationship between the type of fracture, type of limb (dominant versus non-dominant), gender and the
above mentioned measurement criteria values, despite the lack of statistical significance behind these
values, it was noted that dislocated fractures are subject to poorer outcomes and longer periods of time
for patients to reach satisfactory results in comparison with the other types of fractures (three and fourpart fractures, without dislocation). Another variable taken into consideration was time lapse between
injury and operative treatment. Patients who were operated shortly after injury as well as those who
were operated long after injury (approx. 20 days following injury) had the greatest chances of
achieving satisfactory results.
After completing the observational period, the most common findings for internal and external rotation
were 4 on the numerical scale and 1 on the VAS scale. With regards to abduction, flexion, DASH and
CS, the most common findings were, respectively, approximately 75°, 165°, 10 and 70 points, with an
average range of abduction of 90.6°, flexion 116.3° and average values of DASH and CS respectively
at 28.6 and 56 points.
Conclusions
1. the modified technique of rotator cuff reconstruction with the use of polyester bands produced a
large proportion of satisfied patients as seen via prospective observation and was subsequently
correlated with low HTD values.
2. When carrying out a hemiarthroplasty procedure following a proximal humerus fracture, the
smallest possible HTD distance should be aimed for – this is related directly to the position of
the greater tubercle and also the height of prosthesis implantation.
3. The probability of achieving at least 50% positive (good) results with respect to flexion as well
as level of pain (according to the Neer Criteria) requires attaining an HTD value of below 10
mm and 8 mm, respectively; achieving similarly positive results according to DASH and CS
scales requires values of under 11 mm and 5 mm, respectively.
4. Age, gender and limb type (dominant versus non-dominant) did not have a significant influence
on time required to reach patient satisfaction; however, four-part fractures with dislocation of
the humeral head were found to prolong the achievement of satisfactory patient results when
compared with three and four-part fractures without dislocation.
5. Glenohumeral joint hemiarthroplasty, performed even 20 days after injury, may have a similar
positive outcome rate as in those patients who were operated using the same method
“immediately”, so-to-speak. This does however refer to patients who are in good psychophysical condition, properly motivated for rehabilitation, with a relatively simple type of
fracture, allowing accessible isolation and fixation of the humerus tubercles.