The meeting
The Queensland branch of the Australian Orthopaedic Association held its annual scientific meeting in June 2015, attended by over 120 orthopaedic surgeons.
Dr Cutbush was invited to speak on when arthroplasty is indicated in complex upper limb trauma. In a badly fractured shoulder the question is whether to fix the bone or replace the joint, and it turns on the fracture pattern, the blood supply to the humeral head, the quality of the bone and the patient's age and demands.
What complex upper limb trauma means
The term covers fractures around the shoulder and elbow that cannot be treated by simply holding the bone still while it heals. At the shoulder the upper end of the humerus is the part most often involved, usually from a fall onto the arm. In younger patients it takes considerable force; in older patients with weakened bone a fall from standing height can be enough. The fracture may split the humeral head into several fragments, displace the tuberosities to which the rotator cuff tendons attach, and disrupt the blood supply that keeps the head of the bone alive.
Fixing the bone or replacing the joint
Fixation keeps the patient's own joint. The fragments are held with plates, screws, sutures or a nail, and the result depends on them healing in acceptable position and on the humeral head retaining its blood supply. If the head dies, the joint surface collapses and further surgery is needed. Replacement removes that uncertainty by substituting the head with an implant, but commits the patient to an artificial joint, and in an anatomic replacement the tuberosities still have to heal for the rotator cuff to work. Where the bone is poor and the tuberosities are unlikely to hold, a reverse replacement is sometimes chosen instead, because it does not rely on the rotator cuff to raise the arm. Individual results vary.
Why this is argued at meetings
The published evidence does not settle the matter. Series reporting fixation and series reporting replacement are drawn from different patients, and the registry data and the trials do not point uniformly in one direction. Practice consequently varies between surgeons and between hospitals, and the threshold at which a surgeon moves from fixation to replacement is a matter of judgement informed by the fracture in front of them. Invited lectures on indications exist to make that reasoning explicit so that it can be examined. Individual results vary.