We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58). The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly

This clinical study analyzes the long-term outcomes and potential complications of the Grammont's reverse prosthesis in case of trauma in elderly population.

Between January 1993 and May 2010, thirty-seven consecutive patients with 26 three- and four-part fractures and 11 fracture-dislocations, mean age 75 (58 to 92) were evaluated with a mean follow-up of 7.3 years.

Eight complications occurred: 2 complex sympathetic dystrophies, 3 dislocations, 2 deep infections and one aseptic loosening of the base-plate leading to 3 re-operations and 2 prosthesis revisions. The mean Constant's score dropped from 55 at two year follow-up to 52 (20 to 84) at last revision because of an augmentation of the pain and a diminution of the strength which represented 67% of the mean score for the injured side. Mean modified Constant's score was 68. Only 58% were satisfied or very satisfied because of poor internal and external rotations avoiding nourishment with utensils, dressing and personal hygiene when the dominant side was involved.

Two complete glenoid borders, fourteen stable inferior spurs, twenty-one inferior scapular notches including ten of them with medial proximal humeral bone loss or radio lucent lines between the bone and the cement were observed. Notches were more important in size when the follow-up was longer. 62% of the patients had worrying images.

The crossing of the clinical and radiological data showed a degradation of the mean Constant's score (41) for pain and strength in cases of notches with troubling proximal humeral images. In spite of only one case of aseptic loosening at 12 year follow-up, results are disappointing and complications and revisions rates important. The functional result is never equal to the pre-broken state. New developments in design, bearing surfaces and surgical technique and a more long term results will refine the role of the reverse concept for fracture.

Objectives. The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. Methods. A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. Results. A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). Conclusions. Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively. Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178–184. DOI: 10.1302/2046-3758.55.2000596

Introduction. Reverse shoulder replacement is a surgical option for cuff tear arthropathy. However scapular notching is a concern. Newer designs of glenospheres are available to reduce scapular notching. Eccentric glenosphere with a lowered centre of rotation have been shown to improve range of adduction in vitro. We hypothesize that the eccentric glenosphere improve clinical outcomes and reduce scapular notching. Method. This is an ongoing randomized controlled double blind prospective clinical trial. Patients 70 years or older at North Shore hospital who have a diagnosis of cuff tear arthropathy and require surgery were consented for this study. Patients were allocated a concentric or eccentric 36 mm glenosphere intraoperatively, using a computer generated randomization contained in a sealed envelope. The surgical technique and post operative rehabilitation were standardized. Patients were followed up by a research nurse and postoperative radiographs were also taken at regular intervals. Clinical assessment include a visual analogue pain score, subjective shoulder rating, American Shoulder and Elbow Society Score, and Oxford shoulder score. Complications were checked for and radiographs were assessed for scapular notching. Results. There were 23 patients in the concentric and 24 patients in the eccentric glenosphere group. Average age and duration of follow up were comparable. There was no statistical significant difference but there was a trend towards better functional outcome and better range of motion in the eccentric glenosphere group. There was no scapular notching in the eccentric and three cases of scapular notching in the concentric glenosphere group. Conclusions. Reverse shoulder replacement significantly improve pain, function and range of motion in patients with cuff tear arthropathy. Eccentric glenosphere prevents scapular notching in the SMR reverse prosthesis

Introduction. Massive rotator cuff tears in the patient who is too young for a reverse shoulder replacement are a challenging situation. A technique using a ‘Grammont osteotomy’ of the acromion has been developed to allow a comprehensive approach, the so called “Full Monty”. Aim. To document the functional outcome of patients undergoing an acromial osteotomy for the repair of massive tears of the supraspinatus. Methods. Ten patients undergoing this procedure where entered in to the study. The mean age of the patients was 57 years (+/−16) and all bar one were male. Each patient had a pre-operative American Shoulder Elbow Score (ASES), Oxford Shoulder score (OSS), and range of movement documented. These outcome measures were repeated at a minimum of two years, as well as a patient satisfaction questionnaire. Results. The mean ASES preoperatively was 7(+/− 6) and 23(+/−3) post-operatively (p< 0.001). The mean pre-operative OSS was 22(+/−5) and 43(+/−4) post-operatively (p<0.001). 80% of patients deemed their treatment to be “successful” and 90% would recommend the procedure to a friend in the same plight. The mean post-operative forward flexion achieved was 153° (+/−58) and the mean abduction was 142° (+/−37). All patients could sustain a 1kg weight at arms length at 90° of abduction. One patient suffered a superficial wound infection and one patient had a non-union at the osteotomy site. Conclusion. These results suggest that this technique is a good surgical option for a patient with a “massive” rotator cuff tear that is not amenable to standard surgical techniques

Purpose. to analyze the survivorship of the RSA with a minimum 10 years follow up. Patients and Methods. Between 1992 and 1999, 145 Delta (DePuy) RSAs have been implanted in 138 patients. It was a mulicentric study. Initial etiologies were gathered as following: group A (92 cases) Cuff tear arthropaties (CTA), osteoarthritis (OA) with at least 2 involved cuff tendons, and massive cuff tear with pseudoparalysis (MCT); group B (39 cases) -failed hemiarthroplasties (HA), failed total shoulder arthroplasties (TSA), and fracture sequelae; and group C (14 cases) rheumatoid arthritis, fractures, tumor, and instability. Survival curves were established with the Kaplan-Meier technique. Two end-points were retained: -implant revision, defined by glenoid or humeral replacement or removal, or conversion to HA; - a poor clinical outcome defined by an absolute Constant score of less than 30. Results. At the time of review, 47 patients had died with their prosthesis in place and 30 were lost to follow-up. There were 12 revisions, 6 for infections, 3 for glenoid loosening, 1 for dislocation, 1 for glenoid dissociation (by unscrewing), and 1 for humeral loosening. The survival curve to prosthetic removal showed an overall survivorship of 92% at 10 years. Segmentation according to etiology showed a 97% survivorship for group A and 88% for group B This difference was not significant. No patients of group C had a minimum follow up of ten years because there were died or lost to follow up. The survival curve to a Constant score of less than 30 showed an overall survivorship of 90% at 10 years. Segmentation according to etiology showed a significant difference at 10 years in favor of group A (92%) compared to group B (86%) with a break of the curve after 9 years for group B. Discussion. Our results show that the overall survivorship of the reverse shoulder prosthesis to removal is good even 10 years after implantation, in particular if it had been implanted for CTA, OA, or MCT. However, functional results did deteriorate progressively after 9 years in particular if it had been implanted for revision (HA or TSA). Therefore, extreme caution must be observed in relation to the indications for reverse shoulder arthroplasty, especially in younger patients

Objective. To describe demographic data, clinical outcome and short-term survival after shoulder arthroplasty. Materials and Methods. The Danish Shoulder Arthroplasty Register was established in 2004. All 40 Danish hospitals and private clinics where shoulder arthroplasty are performed are participating. Since 2006 where the reporting to the register became mandatory the compliance of reporting has been 88.9%. Data are collected by an internet based clinical measuring system where the orthopaedic surgeon report data such as diagnosis, type of arthroplasty, and demographic data. The follow-up results are collected by sending a questionnaire to the patient 10–14 month after the operation. The questionnaire contains a Western Ontario Osteoarthritis of the Shoulder index (WOOS). Each question is answered on a visual analogue scale with a possible score ranging from 0–100. There are 19 questions and the total score is ranging from 0–1900. For simplicity of presentation the raw scores is converted to a percentage of a normal shoulder. Results. 2320 Shoulder arthroplasties were reported to the register between 2006 and 2008. There were 69.4% women. Median age was 70.6, range 16.3–96.3. 699 arthroplasties (30.0%) were due to osteoarthritis, 98 (4.2%) due to arthritis, 1182 (50.9%) due to a proximal humeral fracture, 179 (7.4%) due to rotator cuff arthropaty, 62 (2.7%) due to caput necrosis and 79 (3.4%) due to other pathology condition such as cancer and revision surgery. 1352 (58.3%) were stemmed hemi arthroplasty, 77 (3.3%) total shoulder arthroplasty, 596 (25.7%) resurfacing arthroplasty and 243 (10.5%) reverse shoulder arthroplasty. 1288 patients (55.5%) returned a complete questionnaire. Median WOOS for all arthroplasties was 58.2, range 0.0–100.0. Median WOOS for arthritis was 59.3, range 13.3–99.8, osteoarthritis 67.9, range 0.0–100.0, a proximal humeral fracture 54.2, range 0.0–100.0, rotator cuff arthropaty 65.6, range 0.0–98.3 and caput necrosis 48.9, range 3.9–95.2. 171 (7.4%) operations were revisions. The most common indications of revision were luxation (2.2%), infection (1.3%), loosening (0.7%) and glenoid attrition (0.6%). Conclusion. To our knowledge there is no previous study with such a large population presenting demographic data and clinical outcome after shoulder arthroplasty. We found good results for the groups of patients diagnosed with osteoarthritis, arthritis and cuff arthropaty. There were poorer results in the groups of patient diagnosed with a proximal humeral fracture and especially caput necrosis

Aims

There is no consensus on the treatment of proximal humeral fractures. Hemiarthroplasty has been widely used in patients when non-surgical treatment is not possible. There is, despite extensive use, limited information about the long-term outcome. Our primary aim was to report ten-year patient-reported outcome after hemiarthroplasty for acute proximal humeral fractures. The secondary aims were to report the cumulative revision rate and risk factors for an inferior patient-reported outcome.

Aims

Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland.

Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) (t-test, p = 0.8443). There was one case each of nonunion, malunion and a broken screw in the elderly population.

This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem.