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25Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-34
Min W, Davidovitch RI, Tejwani NC. Three- and our-part proximal humerus ractures: evolution to operative care. Bull NYU Hosp Jt Dis. 2012;70(1):25-34.
Abstract
The recent increase in lie expectancy is expected to bring
about a concurrent rise in the number o proximal humerus
ractures. Those presenting with signifcant displacement,
osteoporosis, and comminution present distinct clinical
challenges, and the optimal treatment o these injuries re-
mains controversial. As implant technologies and treatment
strategies continue to evolve, the role and appropriateness
o certain operative and nonoperative treatment modalities
are being debated. Prior concerns regarding humeral head
viability orced many physicians to abandon operative
management in avor o nonoperative modalities. However,
with greater appreciation and understanding o the actors
governing humeral head viability, operative intervention isincreasingly used and investigated. Nevertheless, sub-opti-
mal results with earlier implants continue to cloud the debate
between nonoperative and operative treatment modalities.
This paper will review historical considerations, biologic
considerations, and implant considerations in the manage-
ment o three-and our-part proximal humerus ractures.
Proximal humerus ractures account or approximately
5% o all ractures and represent the third most
requent racture o the elderly.1 Most commonly
related to osteoporosis,2 these ractures are oten associ-
ated with elderly co-morbidities that increase their risk or
low-energy alls, such as medication, poor vision, and loss
o protective reexes. However, unlike many osteoporotic
ractures, proximal humerus ractures can also occur in the
ft elderly.3 Due to the anticipated increases in lie expec-
tancy, the number o elderly proximal humerus ractures is
expected to triple by 2030.4
A signifcant majority (85%) o these ractures are mini-
mally- or non-displaced4 and are generally treated nonopera-
tively.5 However, controversy exists regarding the optimum
treatment or displaced ractures. Treatment options range
rom nonoperative to operative modalities. Recent meta-
analyses and larger retrospective and prospective series
have not shown an advantage o one treatment modality
in the management o all displaced ractures.3,6-8 Adding to
this debate, newer implant technologies have challenged theconventional thinking regarding management o displaced
proximal humerus ractures. This paper, written in two parts,
will examine the evolution o treatment o proximal humerus
ractures, and the role that newer implant technologies have
played in changing this paradigm.
Nonoperative Management
As early as 180 AD, Galen described his treatment o
proximal humerus ractures and racture-dislocations.9 Ater
reduction by traction-countertraction methods, the extremity
was immobilized with a valgus mold.9 Because there were
no eective operative methods available, this was considered
the frst described orm o treatment or highly comminutedand unstable proximal humerus ractures. Subsequently, non-
operative management continued to serve as the treatment o
choice or highly comminuted or unstable proximal humerus
ractures, due to lack o eective surgical technologies and
concerns regarding humeral head viability.
Existing literature5,7,10-12 has generally supported nonoper-
ative management; however, while minimally displaced and
non-displaced ractures are preerentially and successully
treated using nonoperative methods with good results,5,7,10-12
Three-and Four-Part Proximal Humerus FracturesEvolution to Operative Care
William Min, M.D., M.S., M.B.A., Roy I. Davidovitch, M.D., and Nirmal C. Tejwani, M.D.
William Min, M.D., M.S., M.B.A., is in the Division o Orthopae-
dic Surgery, University o Alabama at Birmingham, Birmingham,
Alabama. Roy I. Davidovitch, M.D., and Nirmal C. Tejwani,
M.D., are in the Department o Orthopaedic Surgery, NYU
Hospital or Joint Diseases, New York, New York.
Correspondence: Nirmal C. Tejwani, M.D., Department o Or-
thopaedic Surgery, NYU Hospital or Joint Diseases, 301 East
17th Street, Suite 1402, New York, New York 10003; nirmal.
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Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-3426
the studies evaluating the role o nonoperative management
in severely comminuted proximal humerus ractures are
non-validated, non-randomized, and inconclusive.4
Zyto retrospectively investigated the clinical and radio-
graphic results o displaced three- and our-part displaced
ractures treated nonoperatively and ollowed or a minimum
o 10 years, and ound that, despite poor unctional scores
and non-anatomic reductions radiographically, all patientsreport high contentment with their outcomes.6 However,
Zyto’s recommendations or nonoperative treatment were
reserved or three-part ractures, as the our-part ractures
demonstrated more disability than the three-part group. Lill
examined the role o nonoperative management in two-
and three-part ractures and ound that over 60% o their
patients had good and excellent Constant scores. However,
similar to Zyto’s study,6 our-part ractures uniormly had
poor outcomes and poor Constant scores, mostly attributed
to avascular necrosis o the humeral head and resulting
arthrosis.13
Based on these indings and in light o our current
treatment strategies, nonoperative treatment or displaced
three- and our-part ractures is currently reserved or in-
dividuals who are medically contraindicated or surgery
or have low-demand liestyles where the risks o surgery
outweigh its benefts. While these studies suggest that non-
operative treatment is better suited or three-part ractures
(as compared to our-part racture), nonoperative treatment
in these highly displaced ractures may result in signifcant
unctional impairment, shoulder stiness, and malunion.14
Humeral Head Viability and the Evolution tothe Role of Operative Treatment
Despite the potential limitations o nonoperative manage-ment or highly displaced ractures, it was historically held
as the preerred treatment option due to concerns or humeral
head viability. Traditionally, nonoperative measures were
preerred since it was believed that operative management
may disrupt humeral head blood ow and accelerate avas-
cular necrosis.15 With the predominant blood supply o the
humeral head coming rom the arcuate artery (a branch
existing lateral to the bicipital groove and originating rom
the anterior humeral circumex artery), earlier surgical
techniques potentially had a higher risk o disrupting this
critical blood supply. This was evident in the higher rates
o avascular necrosis ater operative treatment o our-part
ractures seen in earlier series.16 However, Neer’s results were the frst to suggest that
nonoperative management o these ractures was a poorer
alternative than operative treatment.16 This fnding, coupled
with improved surgical techniques and implant options,
began to challenge the notion that operative treatment was a
poor option or displaced ractures. Additionally, improved
understanding regarding the actors and risks or humeral
head avascular necrosis lead to urther understanding and im-
proved racture management. While the association between
racture pattern and avascular necrosis rate has not yet been
clearly established,17 it is clear that poor surgical techniques
can increase the risk o avascular necrosis in three-part
ractures to that seen in our-part ractures.18 This urther
clarifes Neer’s original theory, where he believed that three-
part ractures did poorly due to poor surgical technique and
inadequate reductions while our-part ractures did poorly
due to avascular necrosis.16 While Neer’s original theoryhad led him to recommend operative fxation or three-part
ractures with proper surgical technique and arthroplasty
or our-part ractures,16 other investigators now argue that,
despite the higher incidence o avascular necrosis in our-part
ractures as compared to three-parts,19-21 the decision to treat
with operative fxation versus arthroplasty should ideally be
based on multiple actors (including patient age and activity
level, treatment goals, and medical co-morbidities).
Currently, reported rates or avascular necrosis vary rom
3% to 37%.17 In that regard, to minimize these rates, an ac-
curate assessment o humeral head vascularity is crucial in
determining both the viability and the prognosis ollowing
a proximal humerus racture. The Hertel criteria employs
radiographic markers to determine the adequacy and qual-
ity o humeral head vascularity by examining the extent o
metaphyseal extension o the proximal humerus racture and
the amount o medial hinge disruption.22 The investigators
ound that the integrity o the medial hinge and the length
o the posteromedial metaphyseal head extension were key
predictors o vascular disruptions. Specifcally, metaphyseal
head extension less than 8 mm and medial hinge disruption
greater than 2 mm were good predictors o humeral head
ischemia. Recently, Crosby, using tetracycline labeling or
displaced three- and our-part ractures, demonstrated a high
rate o vascular preservation, especially in younger patientsin the anterosuperior aspect o the humeral head.17 In ad-
dition to examining the racture pattern as recommended
by Hertel, an adequate understanding o the humeral head
vascular anatomy, surgeon expertise, the patient’s physi-
ologic status, activity level, and expected outcome should
all be collectively considered to maximize patient outcomes
and minimize humeral head necrosis.17
Operative Modalities
The gradual shit to operative treatment o these complex
ractures was spurred by both an improvement in implant
technologies and techniques, along with concurrent increases
in patient and surgeon expectations or improved unctionaloutcomes. The introductions o locking plates and reverse
shoulder arthroplasties (RSA) have expanded the options
available or treatment, while concurrently generating ur-
ther controversy.
Closed Reduction and Percutaneous Pinning The advantage o closed reduction and percutaneous fxa-
tion is that it can be perormed with minimal surgical dis-
section and can potentially decreased risk o humeral head
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27Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-34
vascular supply disruption. Resch reported percutaneous
fxation o three- and our-part ractures in 27 patients and
ound that at an average o 24-months ollow-up all three-
part ractures demonstrated good to very good unctional
results without avascular necrosis.23 Good radiographic
results were achieved in the our-part ractures but only when
they initially presented in a valgus-impacted manner. Theinvestigators concluded that the medial periosteum serves as
both an important source o vascular supply and as a hinge
or reduction maneuvers (Fig. 1).
This is a technically demanding procedure, especially or
more complex proximal humerus ractures. It is a reasonable
alternative or AO type A ractures with greater than 66%
translation and combined cortical thickness greater than 4
mm, but may not be as good an option in osteoporotic bone
and comminuted ractures since this technique requires
adequate cortical purchase.
Intramedullary Nail Fixation
The use o antegrade intramedullary nail fxation or dis-placed proximal humerus has been reported as an alternative
method o treatment to perorm stable fxation with minimal
sot tissue dissection. Some investigators have also argued
that in addition to the preservation o the periosteal blood
supply, intramedullary techniques limit operative time,
surgical exposure, and length o hospital stay.24
Most studies that have been published on these implants
have investigated their use in displaced proximal humerus
ractures with an intact head ragment.25-28 In a prospective
study by Stedteld,29 112 consecutive patients with displaced
ractures were treated and evaluated. The investigators ound
good unctional results in two- and three-part ractures.
However, the investigators had a 16% complication rate.
They reported that, in our-part ractures, a substantial risk
o post-operative complications and bad unctional results
exist. Koike evaluated 54 patients with two-, three-, andour-part ractures treated with intramedullary nailing30 and
ound that none o the patients developed avascular necrosis.
Seventy-nine percent o patients reported satisactory to ex-
cellent results. However, only three o their treated patients
had our-part ractures.
Adedapo and Ikpeme evaluated the role o intramedul-
lary nail fxation in three- and our-part ractures. 31 At the
one-year ollow-up, the median Neer scores were 89 and 60
or the three- and our-part ractures, respectively. However,
13% o their patients, all o whom were in the our-part
group, continued to have signifcant pain at fnal review.
Complications noted in their series included proximal screw
loosening and extrusion in three patients and avascular ne-crosis in one patient. The use o intramedullary implants is
not ideal or our-part or osteoporotic ractures.
Open Reduction Internal Fixation with Locking
Plate With the advent o locked plates, this technology was ap-
plied to the proximal humerus to provide the advantages o
a fxed-angled implant without the difculties and limita-
tions o frst generation fxed angle (blade plate) fxation.
Figure 1 A, Displaced two-part proximal humerus racture in a skeletally immature patient, B, treated with closed reduction and per-cutaneous pinning. C, Six months post-operatively, ater the pins were removed.
C
B
A
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Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-3428
Currently, most o these implants are precontoured to the
anatomy o the lateral proximal humeral metaphysis and
unction as an internal fxator providing angular stability
(Fig. 2).24 Advantages o these implants include the ability to
obtain anatomic reduction with less racture devitalization,
preservation o the rotator cu integrity, ability to maintain
stable fxation in the ace o signifcant comminution and
osteoporosis, and multi-angle screw fxation.24,32
In a bio-mechanical cadaveric study perormed by Siri, simulated
humerus neck ractures subjected to cyclic loading compar-
ing locking plate constructions to blade plates demonstrated
signifcantly greater torsional stiness o locking plates
and similar bending stability between the two.33 Weinstein
and coworkers34,35 ound similar results, and Edwards and
colleagues35 noted that a locking plate was ar superior to a
proximal humerus nail in both varus bending and torsional
stability. Given that most proximal humerus ractures ail
secondary to rotational and bending moments, such added
stability potentially prevents many o the ailures noted with
other implant types.36,37
Despite these promising biomechanical results, earlyclinical studies evaluating the results o proximal humerus
locking plates were mixed. Kettler reported on 225 rac-
tures treated with the PHILOS (Synthes, Stratec Medical
Ltd, Mezzovico, Switzerland) proximal humerus locking
plate.38 In their series, the investigators reported a high rate
o complications resulting rom technical error, includ-
ing malreduction (14%), screw perorations (11%), and
implant dislocations (4.5%). Similarly, Bjorkenheim39 and
Fankhauser40 reported hardware ailure, nonunion, avascular
necrosis, and malunion as complications in their series using
the PHILOS plate.
Later studies utilizing the plate demonstrated more
promising results. Moonot evaluated the PHILOS plate in 32
patients with displaced three- and our-part ractures, with
an average age o 59.9 years.41 Distinct rom previous stud-
ies, the investigators addressed bone deects with bone grat
substitutes, while tuberosity displacement was treated withanatomic reduction. As a result, the mean Constant score
was 66.5, without signifcant dierences in outcomes when
comparing patients below and above 60 years o age. They
demonstrated a 6% malunion rate and a 3% rate o nonunion
and avascular necrosis. Similar fndings were also ound by
Papadopoulos.42 Shahid,43 however, ound that those who
were elderly or had racture-dislocations perormed slightly
poorer with this fxation.
Other studies44-45 examining the use o locking-plate con-
structs in three- and our-part ractures demonstrated compa-
rable results. Hente44 noted a 16% rate o avascular necrosis;
however, their study did include racture-dislocations (which
were responsible or 80% o these complications). Compli-cations in their series were related to hardware, including
greater tuberosity displacement and screw loosening. Hente
strongly recommended this construct with tension band wir-
ing o the tuberosities as an alternative to prosthetic replace-
ment. Hirschmann46 ound, at one year postoperatively, that
the range o motion o the injured side was 80% that o the
contralateral side. Moreover, absolute and relative Constant
scores signifcantly improved rom six-months (average 56)
to twelve-months (average 65) postoperatively. One over-
Figure 2 A, Displaced three-part proximal humerus racture-dislocation in a 42-year-old patient, B, treated with open reduction internalfxation with a proximal humerus locking plate.
BA
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29Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-34
riding concept that can be garnered rom these studies is the
importance o intra-operative reductions, particularly o the
tuberosities on unctional outcomes.44-45
Solberg retrospectively examined 70 patients older than
55 years o age with three- or our-part proximal humerus
ractures treated with locked plates.47 His study indentifed
two groups based on the initial direction o the humeral head
deormity: those with varus deormity and those with valgusdeormity. Complications o avascular necrosis, humeral
head peroration, loss o fxation, tuberosity displacement,
and varus subsidence were encountered in 79% o those with
varus deormity as compared to 19% o those with valgus
deormity. Constant scores or all three-part ractures were
also signifcantly better than our-part ractures, but dier-
ences between the varus and valgus subgroups were only
signifcant or the three-part group (p < 0.01, as compared to
p = 0.19 or the our-part subgroups). The investigators elt
that, because the locking plate unctions as a tension band
by “pulling” the humeral head out o varus, the initial varus
malalignment placed the implant at a distinct mechanical
disadvantage (especially in osteoporotic bone). Solberg
also ound that ractures with metaphyseal segment length
o less than 2 mm had a higher risk o developing avascular
necrosis. The investigators concluded that the angulation
o the initial deormity and the length o the metaphyseal
segment attached to the articular ragment have a signifcant
inuence on fnal outcomes in these ractures.
Agudelo and coworkers examined the predictors o loss
o fxation in proximal humerus locking plate fxation.48 In
their series, the overall incidence o loss o fxation was
13.7%. They ound that there was a statistically signifcant
association between varus malreduction and loss o fxation
(30.4% when the head-shat angle was below 120° versus11% when the head-shat angle was greater than 120° [p =
0.02]). Similarly, Lee attempted to determine the prognostic
actors or successul clinical outcomes.49 They concluded
that delay in rehabilitation and decreased head-neck shat
angle, caused by lack o medial support, were the primary
actors that led to poor outcome. Other investigators, such
as Micic50 and Clavert,51 also ound that early post-operative
ailures o the locking plate were associated with initial mal-
reduction, poor operative technique (including inadequate
screw length or plate positioning), loss o medial support,
and ailure to adequately fx the tuberosities.
Prosthetic Replacement The use o primary arthroplasty in displaced three- and
our-part proximal humerus ractures was frst proposed by
Neer.16 Non-locking internal fxation gave mixed results, and
concerns regarding avascular necrosis compelled many sur-
geons to treat complex ractures primarily with arthroplasty
options.16,24,52-54 With improved fxation implants available,
arthroplasty has become reserved or treating ractures that
are more technically demanding to reconstruct (i.e., our-part
ractures with complex racture patterns and signifcant ar-
ticular involvement, especially in patients older than 60 years
o age and head splitting ractures). However, unctional
results are only moderately satisactory, despite predictable
pain relie.55 With the increasing popularity o reverse shoul-
der arthroplasties (RSA), the role o arthroplasty has been
revisited. Regardless o which primary arthroplasty option
is selected, aseptic loosening, periprosthetic ractures, inec-
tions, and dislocations can occur and must be considered.24
Hemiarthroplasty The indications or hemiarthroplasty in the management o
proximal humerus ractures, although evolving due to the
advent o locking-plate implants, have traditionally been
or our-part ractures, three-part ractures in older patients
with poor bone quality, racture-dislocations, head-splitting
ractures, and ractures involving greater than 40% o the
articular surace.56-58 Concerns regarding the higher rates
o avascular necrosis in our-part ractures and the tenuous
fxation o racture ragments in osteoporotic bone have led
most surgeons to advocate hemiarthroplasty as the preerred
option over internal fxation (Fig. 3).56 Valgus-impacted
our-part ractures demonstrate a signifcantly lower rate o
avascular necrosis and thus are an exception to this preer-
ence or hemiarthroplasty.3,59
Recent studies have demonstrated that, despite predict-
able pain relie, hemiarthroplasty provides inconsistent
unctional outcomes.55,60,61 These fndings are in contrast to
earlier studies that demonstrated more reliable unctional
results.56,57,62,63 It has been shown that early passive range o
motion post-operatively, ollowed by long-term active range
o motion and strengthening, is essential to achieve optimal
outcomes ater shoulder hemiarthroplasty.62,64,65 However,
the insufcient bony healing o displaced tuberosities a-ter intra-operative fxation at the stem o the prosthesis,
malpositioning o the tuberosity ragments, and incorrect
positioning o the prosthesis are probably the most important
actors determining the outcomes o this treatment modal-
ity.24,36,64,66,67
Approximately 4% to 50% o shoulders treated with
hemiarthroplasty experience malunion or nonunion o tuber-
osity fxation, resulting in the most signifcant complication
ater hemiarthroplasty or proximal humerus ractures.58,65,68
A recent multicenter study by Kralinger and associates re-
vealed that tuberosity positioning is a signifcant actor in
the unctional outcome o hemiarthroplasties or ractures
o the proximal humerus; however, pain did not correlatewith displacement o the tubesrosity.62 These fndings were
also reported by Mighell57 and Coleman69 in their reviews.
Aside rom devascularization and inadequate fxation that
may lead to tuberosity nonunion, Boileau determined that the
actors most commonly associated with tuberosity malunion
include poor intra-operative positioning o the prosthesis,
age, sex, and initial malposition o the greater tubosity.68
Due to importance o anatomic restoration o humeral
head position, studies have assessed the use o intra-operative
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Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-3430
anatomic landmarks, such as the bicipital groove, to deter-
mine the appropriate 30° to 40° o retroversion or prosthesis
orientation.67 Christoorakis and colleagues proposed using
the contralateral humerus to estimate the proper retroversion
or each patient as an individualized approach to restoring
native anatomy.64 However, a recent study by the same inves-
tigator has ound that, when evaluating the mean Constant
scores using these two techniques, there is no dierence.64
However, the results o this study are limited secondary to
its small sample size.
Use o bony landmarks when assessing or proper pros-
thesis orientation is limited by the distortion that occurs in
complex ractures. Murachovsky validated the use o the
pectoralis major tendon as a reproducible landmark or ac-curate restoration o humeral height with hemiarthroplasty
reconstruction.70 By dissecting 40 cadaveric shoulders, he
determined that the distance between the upper border o
the pectoralis major tendon insertion on the humerus and
the top o the humeral head averaged 5.6 cm ± 0.5 cm. This
provides an easily reproducible intraoperative check o
prosthetic humeral head height.
The third actor inuencing outcome with arthroplasty
is the union o the tuberosities. A cadaveric study by de
Wilde examining the strength o fxation o the bone-ten-
don interace o the rotator cu to the articular rim o the
hemiarthroplasty prosthesis ound that it is strong enough
to resist racture ragment displacement under orces as-sociated with activities o daily living.71 Frankle and col-
leagues determined that circumerential cerclage around the
tuberosities decreases interragmentary motion and strain,
maximizes racture stability, and acilitates post-operative
rehabilitation.72 However, Pijls and associates presented a
new sling technique or tuberosity fxation in uncemented
hemiarthroplasty or severe ractures o the proximal hu-
merus, due to concerns regarding suture damage rom the
edges o the drill holes in traditional tuberosity fxation
techniques.73 The investigators elt that in some cases the
sutures placed by standard drill holes ailed due to suture
cut-out through osteoporotic bone, leading to suboptimal
tuberosity positioning. The investigators ound that their
sling technique provided better tuberosity positioning, stable
fxation (which they elt translated to improved unctional
outcomes), patient satisaction, and pain scores as compared
to traditional drill-hole techniques.
Heterotopic ossifcation, glenoid degeneration, prosthetic
loosening, and axillary nerve injury may also be seen with
hemiarthroplasty treatment. Reported rates o heterotopic
ossifcation range rom nine to 56%.57,65,68 While the studies
do not specifcally indicate a reason or this dierence, it has
been shown that patients with hemarthrosis or concomitantrotator cu tears have a signifcantly higher risk o hetero-
topic ossifcaiton.24,74,75 Mighell and coworkers57 have also
reported an 8% rate o glenoid degeneration at an average
o three-year ollow-up, while Parsons and associates76 have
determined that unctional outcome, as determined by the
Constant score, is negatively correlated with joint space
narrowing and glenoid degeneration.77 Other complications,
such as prosthetic loosening, inection, and nerve injury are
rarer, occurring at reported rates o 3% to 6%,64,65 1% to
2%,57,63 and less than less than 1%,57,63-65 respectively.77
The optimal timing o hemiarthroplasty treatment has also
been evaluated. Acute reconstruction is technically easier
and has been shown to be preerable to delayed hemiarthro-plasty. Mighell57 ound statistically signifcant improvement
in ASES scores in patients treated within 2 weeks o initial
injury, and Becker78 determined that ractures treated early
with hemiarthroplasty showed better shoulder motion by
video motion analysis and clinical outcomes when treated
within 2 weeks o injury. In contrast, Prakash and cowork-
ers65 did not fnd any dierence in his series o early (less
than 30 days) versus late (greater than 30 days, average
time rom injury to surgery was 13 months) treatment with
Figure 3 A, Displaced our-part proximal humerus racture-dislocation in a 62-year-old patient, B, treated with hemiarthroplasty.
BA
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31Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-34
hemiarthroplasty with regards to range o motion.77 While
the optimal timing on hemiarthroplasty replacement remains
controversial, it can be inerred rom these studies that earlier
surgery tends to lead to better outcomes.
Reverse Total Shoulder Arthroplasty Concerns related to the positioning and healing o the tuber-
osity in hemiarthroplasty have led to the development anduse o reverse shoulder arthroplasty (RSA) or the treatment
o proximal humerus ractures, particularly in the elderly.
By converting the glenoid into a spherical head and the
head o the humerus into a socket, the center o rotation o
the glenohumeral joint is medialized, giving the deltoid a
more eective moment arm (Fig. 4).79 This new relationship
eliminates the detrimental eect generated rom rotator cu
defciency resulting rom tuberosity malunion or nonunion.
Boileau80 and Cazeneuve evaluated the Grammont reverse
shoulder prosthesis in traumatic cases and, although evaluat-
ing only a small series and reporting on early results, ound
this method to be acceptable.
Buquin and colleagues evaluated the reverse total shoul-
der arthroplasty in 43 consecutive patients with a mean age o
78 years in a prospective review with short-term ollow-up.79
Patients with three- or our-part ractures o the proximal
humerus were treated with a RSA. Patients were ound to
have satisactory clinical outcomes, with a mean anterior
elevation o 97° and a mean active external rotation in abduc-
tion o 30°. The mean Constant scores, however, were only
44. Complications included reex sympathetic dystrophy,
neurologic injury (most o which resolved), and anterior
dislocation. Despite these fndings, the investigators pro-
posed that RSA is an attractive alternative that still requires
long-term investigation. A recent study by Cazeneuve andCristoari evaluating radiographic outcomes at an average
ollow-up o 6.5 years demonstrated that, or acute proximal
humeral ractures in the elderly, unsatisactory radiographic
images were obtained in 70% o cases.81 These unsatisac-
tory changes included evidence o glenoid loosening and
scapular notching. However, only one revision was required
at 12-year ollow-up.
Levy and colleagues examined the use o RSA as a treat-
ment or ailed hemiarthroplasty or proximal humerus rac-
tures.82 Over a fve year period, 29 patients with a mean age
o 69 previously treated with hemiarthroplasty were revised
to a RSA (or glenoid arthritis or rotator cu defciency rom
tuberosity malpositioning). Proximal humeral allograts
were used in cases where signifcant bone deects were en-countered. Ater ollow-up or an average o 35 months, the
average total ASES score improved rom 22.3 preoperatively
to 52.1 (p < 0.001). There were also signifcant improve-
ments noted in the ASES pain score, orward exion, and
abduction. There was a trend towards improvement in the
ASES unctional score, but it was not statistically signif-
cant. The overall complication rate, however, was 28%. The
investigators concluded that the RSA oers a salvage-type
solution to the problem o ailed hemiarthroplasty due to
glenoid arthritis, tuberosity and rotator cu defciency, and
implant ailure.
Currently, the role o RSA in primary and late salvage
treatment o proximal humerus ractures is still being inves-
tigated. However, early evidence does show that it may have
a role in primary treatment when tuberosity reconstruction is
not a viable option or when salvage rom a previously ailed
hemiarthroplasty is required.
Conclusion
Although no level one data exists, the literature suggests
that three-part ractures are better treated with internal
fxation with locking plates,83 especially those presenting
with initial valgus displacement and those that possess a
longer medial metaphyseal segment.47 Recommendations
or most displaced three-part ractures include internalfxation, with the option o prosthetic replacement or those
not amenable to humeral head preservation techniques.3,18
I surgical treatment is chosen, select our-part ractures in
the elderly may be better treated with arthroplasty, with the
exception o the valgus impacted our-part ractures.3,23,59
One must understand that the ability to re-establish adequate
Figure 4 A, Displaced our-part proximal humerus racture in an 84-year-old patient, B, treated with reverse shoulder arthroplasty.
BA
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Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-3432
head-neck shat angulation, anatomic reduction o the tu-
berosities, and obtain adequate post-operative rehabilitation
are vital to success and help determine optimal outcome
i this option is chosen.47-49,84 The role o reverse shoulder
arthroplasty is currently being investigated, but may prove
to be another tool in the armamentarium in the treatment o
these complex injuries.
Regardless o implant technology, sound technique, accu-rate anatomic reduction, and proper patient selection are the
most important actors in determining treatment success.84
Thereore, the surgeon is not advised to use one treatment
option or all types o displaced proximal humerus ractures.
The various methods available at the surgeon’s disposal
serves as a spectrum o treatment options that, when used
appropriately, can maximize the outcomes o this difcult
clinical challenge.
Disclosure Statements Drs. Min and Davidovitch have nothing to disclose. Dr.
Tejwani or a member o his immediate amily is a member o
a speakers’ bureau or has made paid presentations on behal
o Stryker, Biomet, and Zimmer and has received research
or institutional support rom Biomet. Dr. Tejwani is also a
product developer or the Biomet OptiLock Upper Extremity
Plating System Proximal Humeral Plates.
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