Aims. This study aimed to gather insights from elbow experts using the Delphi method to evaluate the influence of patient characteristics and fracture morphology on the choice between operative and nonoperative treatment for coronoid fractures. Methods. A three-round electronic (e-)modified Delphi survey study was performed between March and December 2023. A total of 55 elbow surgeons from Asia, Australia, Europe, and North America participated, with 48 completing all questionnaires (87%). The panellists evaluated the factors identified as important in literature for treatment decision-making, using a Likert scale ranging from "strongly influences me to recommend nonoperative treatment" (1) to "strongly influences me to recommend operative treatment" (5). Factors achieving Likert scores ≤ 2.0 or ≥ 4.0 were deemed influential for treatment recommendation. Stable consensus is defined as an agreement of ≥ 80% in the second and third rounds. Results. Of 68 factors considered important in the literature for treatment choice for coronoid fractures, 18 achieved a stable consensus to be influential. Influential factors with stable consensus that advocate for operative treatment were being a professional athlete, playing overhead sports, a history of subjective dislocation or subluxation during trauma, open fracture, crepitation with range of movement, > 2 mm opening during varus stress on radiological imaging, and having an anteromedial facet or basal coronoid fracture (O’Driscoll type 2 or 3). An anterolateral coronoid tip fracture ≤ 2 mm was the only influential factor with a stable consensus that advocates for nonoperative treatment. Most disagreement existed regarding the treatment for the terrible triad injury with an anterolateral coronoid tip fracture fragment ≤ 2 mm (O’Driscoll type 1 subtype 1). Conclusion. This study gives insights into areas of consensus among surveyed elbow surgeons in choosing between operative and nonoperative management of coronoid fractures. These findings should be used in conjunction with previous patient cohort studies when discussing treatment options with patients. Cite this article: Bone Joint J 2024;106-B(10):1150–1157

The function of the shoulder joint has traditionally been evaluated based on range of motion (ROM) in predefined anatomical planes and also by using functional scores, which assessed shoulder function based on the ability to conduct certain activities of daily living (ADLs). However, measuring ROM only in terms of flexion-extension, abduction-adduction and internal-external rotation may under-account for the 3-dimensional mobility of the shoulder joint. Furthermore, functional scores, such as the Oxford shoulder score or American shoulder and elbow surgeons (ASES) score, are subjective measures and are not an accurate assessment of shoulder joint function. In this study, we proposed the use of the globe model of the shoulder joint which can be used to provide an objective measure of the global ROM and also function of the shoulder joint – termed the Global and Functional arc of motion (GAM and FAM). Thirty-three young, healthy male patients (23.7 ± 1.5 years) were recruited and tasked to perform eight ADLs and a full humeral circumduction movement which represented their active global ROM. Reflective markers were placed in accordance to the International Society of Biomechanics (ISB) and optical-based motion capture cameras were used to track relative motion of the dominant humerus with respect to the thorax (i.e. thoracohumeral motion). The GAM and FAM were generated by plotting the thoracohumeral on a spherical coordinate system during global ROM and the eight ADLs respectively. Shoulder joint global ROM and function were quantified by calculating the area enclosed by the closed loop of GAM and FAM respectively. The spherical coordinate system, or more commonly referred to as the globe model, describes thoracohumeral movement using plane of elevation (POE), angle of elevation (AOE) and rotation. In our model, POE and AOE represents longitude and latitude of the globe respectively, and rotation is depicted using a red-green-blue (RGB) colour scale. Overall, subject's GAM of the shoulder joint covered an area of 4.64 ± 0.48 units2 compared to only 1.12 ± 0.26 units2 for the FAM. Subjects only required 24.4 ± 5.7 % of their global shoulder ROM for basic daily functioning. Studies that reduced shoulder joint movement into planar movements (i.e. sagittal, coronal and rotation) do not account for the 3-dimensional nature of the joint and doing so may overestimate the requirement of the shoulder joint for ADLs relative to its ROM in each plane. While others have attempted to use the globe model, such studies tend to reduce the globe into its descriptive angles (i.e. POE, AOE and rotation), reducing its intuitiveness. In contrast, by keeping an intact globe, the proposed globe model was more intuitive and yet capable of quantifying both shoulder joint global ROM and function. Doing so, we found that young healthy subjects only required approximately a quarter of their global ROM of the shoulder joint to complete the most common daily tasks, which was significantly less than what was previously reported

Aims

The conventionally described mechanism of distal biceps tendon rupture (DBTR) is of a ‘considerable extension force suddenly applied to a resisting, actively flexed forearm’. This has been commonly paraphrased as an ‘eccentric contracture to a flexed elbow’. Both definitions have been frequently used in the literature with little objective analysis or citation. The aim of the present study was to use video footage of real time distal biceps ruptures to revisit and objectively define the mechanism of injury.

Aims

The aim of this study was to analyze how proximal radial neck resorption (PRNR) starts and progresses radiologically in two types of press-fit radial head arthroplasties (RHAs), and to investigate its clinical relevance.

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p − 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8°, p = 0.003) and for reduction in pain (difference on a visual analogue scale −1.7 cm, p < 0.0005)

Background. The purpose of this retrospective study was to examine the functional outcomes of patients treated for isolated fracture of the greater tuberosity (GT) and to determine how their outcomes were affected by fracture pattern, treatment choices, associated shoulder injuries, the post fixation displacement of GT fragment and the time delay between injury and fixation. Methods. Forty-eight (28 male and 20 female) patients (mean age 45 years) treated at our institution between 1999–2009 matched our inclusion criteria. Thirty-five patients were treated surgically and 13 conservatively. Functional outcome was assessed using Oxford scores (OS), University of California and Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow surgeons (ASES). The outpatient follow up time required and the presence of other shoulder injuries, time delay to surgery and the time off work were also recorded. Results. Outcome scores for patients who sustained simple vs comminuted fractures were not significantly different (OS = 41.8 vs 41, ASES 23.8 vs 23.4, UCLA 26.6 vs 26.3). Time taken off work was less in those who had a comminuted vs a simple fracture (21 vs 30 weeks). Shoulder dislocation was present in 77% and patients had a significantly worse outcome than those with no dislocation (OS = 40.6 vs 44, ASES 22.9 vs 26). Rotator cuff repair was required in 21% of patients and was also associated with a worse outcome (OS 42.8 vs 36.8, ASES 24.5 vs 20.5). Post fixation displacement of the GT fracture of < 5 mm led to a significantly better outcome than displacement >5mm (OS = 43 vs 37, ASES = 25.6 vs 17.7, UCLA 28.2 vs 21.3). Conclusion. Isolated fractures of the greater tuberosity have a worse outcome if they are associated with shoulder dislocation, rotator cuff tear and post fixation displacement of >5mm

Summary. Analysis of existing data of patients who had undergone debridement procedure for osteoarthritis (OA) of glenohumeral joint showed improvement in disability at a minimum of one year following surgery. Injured workers were significantly younger and had a poorer outcome. Introduction. There is little information on debridement for OA of the shoulder joint. The purpose of this study was to examine factors that affect the outcome of arthroscopic debridement with or without acromioplasty /resection of clavicle of patients with osteoarthritis of the glenohumeral joint, in subjective perception of disability and functional range of motion and strength at a minimum of one year following surgery. Patients and Methods. Existing data of patients with advanced OA of the glenohumeral joint who had undergone debridement were used for analysis. These patients were not good candidates for shoulder arthroplasty due to a young age, high activity level, or desire to avoid major surgery at the time of assessment. Arthroscopic debridement included removal of loose bodies, chondral flaps, and degenerative tissue. Resection of the lateral end of the clavicle or acromioplasty was performed as clinically indicated for management of osteoarthritis of the Acromioclavicular (AC) joint or subacromial impingement respectively. Disability at a minimum of 12 months following surgery was measured by the American Shoulder and Elbow Surgeon's (ASES) assessment form, Constant-Murley score (CMS), strength, and painfree range of motion (ROM) in four directions. Impact of sex, age, having acromioplasty or resection of clavicle, and having an active work-related compensation claim was examined. Results. Seventy-four patients (mean age= 55, SD: 14 (range: 25–88), range: 35–86, 34 females, 40 males) were included in analysis. The average symptom duration was 5.8 years. Fifty nine (80%) patients had an associated subacromial decompression [55 (74%) had acromioplasty, 32(43%) had resection of the lateral end of the clavicle, and 28 (38%) had both procedures]. Nineteen (26%) patients had a work-related compensation claim related to their shoulder. This group was significantly younger than the non-compensation group (45 vs. 58, p=0.0001). Paired student t-tests showed a statistically significant improvement in scores of ASES and CMS (p<0.0001), strength (p=0.001) and painfree range of motion (p=0.01) at a minimum of 1 year follow-up. The ANCOVA model that incorporated sex, age, additional decompression (AC resection or acromioplasty), compensation claim and pre-op scores, showed that the pre-op scores and having a work-related claim were the most influential predictors of post-op scores of ASES, CMS, and ROM. The post-op strength was the only factor that was affected by sex, age and having a work-related claim. Discussion/Conclusion. Arthroscopic debridement with or without acromioplasty /resection of the lateral end of the clavicle improved disability, painfree range of motion and strength in patients suffering from osteoarthritis of glenohumeral joint at a minimum of one year following surgery. Patients with an active compensation claim related to their shoulder were significantly younger and had a poorer outcome

Background: Intra-articular distal humeral fractures in the elderly are difficult to treat. There is evidence in the literature to support the use of both open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA) as primary procedures, although we have been unable to find any direct comparisons of outcome. Methods: This study reports the results of ORIF in 12 elderly patients with distal humeral fractures and compares the outcome with 12 matched patients who had undergone TEA. All procedures were performed by two Consultant elbow surgeons. The Coonrad-Morrey TEA was used in all cases of TEA and a double-plating technique was used in all ORIFs. Both groups of patients were similar with respect to fracture configuration, age, sex, comorbidity and hand dominance. The mean follow-up in both groups of patients was over 30 months. Results: At final review, patients who had had a TEA had a mean Mayo score of 91 and a range of flexion/extension of 90 degrees. There was 1 superficial wound infection that resolved with antibiotics, 1 temporary radial nerve palsy, and 1 case of heterotrophic ossification The ORIF group had a mean Mayo score of 89 (p> 0.05) and a range of flexion/extension of 112 degrees (P=0.03). There was 1 case of heterotrophic ossification, 2 cases of ulnar nerve compression that needed decompression and 1 superficial wound infection that resolved with antibiotics. All the fractures united. Conclusion: This study indicates that both treatment modalities can lead to excellent results. ORIF has the advantage of preserving the joint and once union has occurred has a low risk of long term complications

Purpose of the study: Although the role of the radial head is clearly established regarding elbow stability, it cannot always be preserved after complex fractures. Association with a posteriolateral dislocation, besides the risk of short-term recurrent dislocation, raises the problem of long-term osteoarthritic degeneration. Certain authors advocate a metal prosthesis which works like a spacer in lieu of the head; their mid-term results have been encouraging, but should complete resection with suture of the medial ligament plane be ruled out definitively?. Material and methods: We reviewed 13 files of patients who had had an initial resection of the radial head after trauma. For seven of these patients, there was an associated dislocation; the medial ligament structures were sutured. All patients were reviewed with mean 13 years follow-up (5–15) and evaluated clinically with the American Shoulder and Elbow Surgeon (ASES) system to establish the Mayo Clinic Elbow Performance (MCEP) score. Osteoarthritis of the ulnar trochlea was analysed on the plain x-rays, completed by an axial view, using the Morrey radiographic classification of 4 stages. Results: There were not cases of recurrent dislocation. According to the Broberg and Morrey index, 92% of patients had good outcome with total resumption of occupational activities; there was no difference between patients with and without dislocation. All patients developed grade 1 or 2 osteoarthritis, with very good clinical tolerance. All were satisfied with their operation despite efforts to spare joint movements. Discussion: The studies evaluating the use of radial head prostheses have reported similar findings for functional outcome. Radiographic degeneration of the ulnar trochlea is also comparable. Immediate rehabilitation is necessary to prevent loss of range of motion and warrants surgery to stabilize the joint as wells as possible use of an adapted dynamic orthesis. Conclusion: Resection of the radial head without prosthetic reconstruction remains a reasonable option when the head cannot be saved. Associated dislocation implies repair of the medical collateral ligament. At long-term, the functional impairment is minimal despite the moderate osteoarthritis; the problematic of implant survival is avoided

Aims: To review the early results of shoulder arthroplasty in the weight bearing shoulder of long term pareplegic patients. We have been unable to find previously published results of this subgroup of shoulder arthroplasty patients in the litterature. Method: The case notes and X-rays of 5 female patients who had undergone shoulder arthroplasty were analysed. These patients all had longstanding paraplegia and were wheelchair bound. All patients has been prospectively scored with the American Shoulder and Elbow Surgeon’s (ASES) function score and the Constant score. Results: The patients had a mean age of 70 yrs (61–88) at the time of surgery. Three of the 5 shoulders and rotator cuff tears at the time of surgery, 2 of which were repaired. The results are summarised in the table. There was no radiological evidence of failure apart from the migration of the single cemented glenoid component. Conclusion: In view of the satisfactory improvement in pain in particular following these procedures, we feel that it is reasonable to continue to offer this procedure in this subgroup of patients. We will however remain vigilant with regard to any further complications arising because of the increased loading in these prostheses at the medium and long term

A systematic review of the English language literature has suggested that the performance of linked and unlinked elbow replacement implants differ in terms of function, survival and mode of failure; however, in this review, only one comparative series using contemporary implants was identified. We have performed a cohort study of Kudo, Souter-Strathclyde and Coonrad-Morrey elbow replacements performed at a single centre by or under the direct supervision of a single Consultant shoulder and elbow surgeon to see if these findings were reflected in clinical practice. The first forty implantations in patients with Rheumatoid arthritis for each device have been reviewed with respect to surgical complications, elbow function and implant survival. The follow-up was shorter for the Coonrad-Morrey cohort. In terms of pain relief and range of motion, the performance of the implants was comparable. The mode of failure was different, with no dislocations/ instability seen with the linked Coonrad-Morrey implants. The loosening rate of the Coonrad-Morrey implants (both clinical and radiographic) was lower, albeit with a shorter follow-up period. The loosening rates seen in this series were higher than those previously reported in the English language literature. We conclude that the functional performance of the implants, at similar stages of the surgical learning curves, are similar in patients with Rheumatoid arthritis, but that use of a linked implant removes the risk of post-operative instability and may reduce the risk of the radiographic and clinical loosening

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals. Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors. 16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component. Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant

To date there has been only one published series of elbow arthroplasty in patients with Juvenile Idiopathic arthritis. These patients pose particular problems because of the size and variable shape of the humerus and ulna together with the soft tissue contractures and bony erosion which can sometimes be severe. We have reviewed the results of elbow arthroplasty using the unlinked Kudo 5 and the linked Coonrad-Morrey implants which in our practice have different indications dependent upon bone stock and stability. Methods 19 total elbow replacements in 13 patients with juvenile idiopathic arthritis were performed by 1 specialist elbow surgeon, the senior author. 13 of these are Kudo 5 and 6 are Coonrad-Morrey implants. The mean age at operation was 39 years. 6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision. No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results Preoperatively 7 had moderate pain and 12 had severe pain. Postoperatively the pain was rated as none by 13 and mild by 6. The average Mayo Elbow Score improved from 26 preoperatively to 81 postoperatively. The mean arc of flexion/extension improved from 85 to 108 degrees.12 elbow replacements had intra and post-operative complications and 2 elbows have been revised. Conclusions The medium-term results of Total Elbow Replacements in patients with Juvenile Chronic Arthritis are acceptable and comparable to the only other published series which also records a high complication rate

Purpose: The purpose of this study was to examine the measurement properties of four commonly used disability measures. We hypothesized that all measures would have a high (0.8 or > 0.8) internal consistency and ability to discriminate between men and women’s level of disability. A moderate convergent validity (0.5 to 1.00). Method: This was a prospective longitudinal study of patients with advanced primary osteoarthritis of glenohumeral joint who underwent a Total Shoulder Arthroplasty (TSA). Four measures [Western Ontario Osteoarthritis Shoulder (WOOS) Index, the American Shoulder and Elbow Surgeon’s (ASES) assessment, Constant-Murley Score (CMS), and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH)] were completed 2–3 weeks before surgery and at 6 months after surgery. The measurement properties were examined in:. internal consistency as a measure of reliability,. cross-sectional and longitudinal convergent validity,. known group validity, and. sensitivity to change at 6 months following surgery. Analysis involved calculating Cronbach Coefficient Alpha to measure internal consistency. Convergent validity was examined by the Pearson correlation coefficient. Analysis of Variance examined the extent of known group validity. The Standardized Response Mean (SRM) was used to measure the relative sensitivity to change. Results: Seventy patients (mean age: 65, range: 35–86, 44 females, 26 males) participated in the study. The Cronbach Coefficient Alpha was high at 0.91, 0.86, and 0.83 for WOOS, ASES, and QuickDASH respectively. Cross-sectional convergent validity was moderate with correlations varying from 0.54 to 0.79. Longitudinal convergent validity ranged from 0.58 to 0.88. All measures were able to discriminate between men and women at p< 0.05 with Cohen’s d of 1.07, 0.85, 0.82, and 0.55 for QuickDASH, CMS, WOOS, and ASES respectively. The SRM was 2.41, 2.17, 1.88, and 1.63 for WOOS, CMS, ASES and QuickDASH respectively. Conclusion: All four disability measures were valid and reliable in candidates for TSA. The WOOS, a disease-specific outcome demonstrated a higher reliability and sensitivity to change than other measures. QuickDASH had a better ability to differentiate between men and women. Clinicians may not gain additional information by administrating multiple similar outcome measures. Researchers will decrease their chance of declaring a statistical significance by choosing one primary outcome measure

Background: Total elbow prostheses are broadly classified into linked and the unlinked categories. We have looked at long-term results of unlinked Kudo 5 total elbow replacement used in the treatment of patients with rheumatoid arthritis in 2 hospitals. Methods: 87 Kudo 5 Total elbow replacements in 70 patients with adult rheumatoid arthritis were performed at Wexham Park Hospital, Slough and City Hospital, Nottingham by 2 specialist elbow surgeons, the senior authors. 16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films. Results: Preoperatively 6 had moderate pain and 56 had severe pain. Postoperatively the pain was rated as none or mild by 58 and moderate by 4. The average Mayo Elbow Score improved from 37 preoperatively to 86 postoperatively. The mean arc of flexion/extension improved from 60 to 99 degrees. There were 14 complications including ulnar neuropraxia, fracture, dislocation, triceps rupture and loosening. 4 cases were revised, 2 for aseptic and 2 for septic loosening. Postoperative radiographs showed 5 cases with loosening around the ulna component. Conclusions: The long-term results using the Kudo 5 elbow prosthesis in patients with rheumatoid arthritis are acceptable and comparable to other series reported of this implant. To date this is the largest series reported with the longest follow up using this implant

Background: Flail or unstable elbow presents a difficult challenge for the elbow surgeon. This study reports the medium-term follow-up of 30 elbows in 25 patients, treated with two different designs of sloppy-hinged prosthesis: the Coonrad-Morrey and the snap-fit Souter-Strathclyde. Methods: All patients treated over a 12 year period by a single surgeon were identified and reviewed. This included a detailed history of indications, complications, and subjective assessment (including Mayo Elbow Performance Scores, subjective satisfaction score, and SF-12 mental and physical disability questionnaire), as well as examination and radiographic review of preoperative and most recent xrays. Results: 30 elbows in 25 surviving patients were assessed at an average postoperative period of 5.7 years. 17 Coonrad-Morrey and 13 snap-fit Souter-Strathclyde prostheses were implanted. 4 elbows (13.3%) have been revised. Average Mayo Elbow Performance score was 78.8 out of a top score of 100, with 15 classed as excellent, 5 good, 4 fair and 6 poor. Average subjective satisfaction with the operation was 4.5 out of a top score of 5. There was an average flexion arc of 104.7°, with 18 elbows ≥100°. 3 of the 17 Coonrad-Morrey elbows (17.6%) and 3 of the 13 snap-fit Souter-Strathclyde elbows (23.1%) demonstrated at least Grade 3 humeral radiolucency at the bone-cement interface. In the ulna, these figures were 6 out of 17 (35.3%) for Coonrad-Morrey elbows and 2 out of 13 (15.4%) for snap-fit Souter-Strathclyde elbows. Conclusions: Sloppy-hinged elbow replacement is a safe procedure with a high subjective satisfaction level. Its main indication is as a salvage operation in patients with a functionally useless elbow due to failed primary replacement or non-union of distal humeral fracture

Introduction: The treatment of Complex Proximal Humeral Fractures and Fractures associated with Dislocation is not still resolved. Internal Fixation sometimes is not possible due to comminuted and osteoporotic bone which is commonly found in this kind of Fractures. The use of Hemiarthroplasty in this situation, not always achieves a good functional outcome, usually related to a Non Union or Malunion of the Tuberosities. We began using Reversed Shoulder Arthroplasty in this Fractures due to good results this implant had had in Glenohumeral Arthritis associated a Rotator Cuff Deficiency. Material and Methods: From January 2004 to December 2008 we have treated 50 patients with Complex Proximal Humeral Fractures with a Reversed Shoulder Arthroplasty,38 were women and 12 were men with a mean age of 76 (38–84). The mean follow-up time was 20 months (10–36). We have used a Lima Reversed Arthroplasty in all the cases. The dominant arm were involved in 65 % of the patients. The Deltopectoral approach were used in all the cases. Thirty-five patients (70 %) were treated in less than 30 days after the fracture and 15 (30 %) were treated 30 days or more since the fracture happened. The operations were performed by 6 surgeons, but only 3 of them have performed more than 10 operations. We used the Constant Score and the American Shoulder and Elbow Score to evaluate the outcome of the implant. The preoperative movement were estimated on the mobility score of the contralateral shoulder. Results: The mean Constant and the mean modified Constant Score were 55 (23 to 73) and 70 (34 to 95). The average range of motion was 105 (45–140) for anterior elevation and 100 (35–125) for abduction. The mean modified American Shoulder and Elbow Surgeon was 64 (44–82). The average operation time was 105 minutes with a range (60–170). The main clinical complications has been: Three intraoperative Fractures of Glenoid, 2 post operative Glenoid Fractures, 2 Brachial Plexus Paralysis, 2 cases of Cubital Neuroapraxia, 2 Dislocations of the Prosthesis,2 superficial infections and 1 deep infection. Radiography it has been found Scapular Notch in 17 patients (34%), Periprothesic Calcification in 42 (84 %) and migration of the Tuberosities in 22 (44%). Conclusions: We have had better results in acute situations than chronics ones. Most of the complications occurs in the group of patients treated in more than 30 days since the Fracture has happened. The Reverse Shoulder Arthroplasty is an alternative to the Hemiarthroplasty, and an important tool which an Orthopaedic Trauma Surgeon has to consider, to resolve this kind of Fractures specially in elderly patients

Introduction and Objectives: The treatment of complex fractures of the humerus continues to be a challenge. The purpose of this study is to evaluate the results of hemiarthroplasty in the treatment of these kinds of fractures. Materials and Methods: This is a retrospective analysis of 22 cases of fractures treated with hemiarthroplasty between 1998 and 2002 with a minimum follow-up time of one year. Neer’s classification was used. All fractures were in 3 or 4 fragments or were fracture/dislocations. Epidemiological, surgical, and rehabilitative data were recorded. Results were analyzed using Constant’s test and American Shoulder and Elbow Surgeon (ASES) criteria, which evaluate pain, mobility, strength, stability, and daily activities. Results: Patients were predominantly female (63.6%), with an average age of 69.5 years, and the right side was affected in 54.5% of cases. Average Constant score was 49.2 points, with the primary problem being lack of strength. In 90.9% of patients, there was no pain or only slight pain on the ASES scale. Average active elevation was 92.8° with anteropulsion of 60°–90° in 45.5% and 90°–120° in 45.5% of patients. Average external rotation with the arm at 90° was 15°, and average passive internal rotation was 54.1%. There were 81.8% of patients that were able to raise their hand to the level of L5 or higher. In more than 85% of cases, patients were able to maintain perineal care, put a hand in a back pocket, use silverware, or dress themselves with little or no difficulty. Combing hair, sports, throwing, and raising objects presented the greatest problems. Discussion and Conclusions: As in most other studies, results were modest in terms of mobility and strength, but in view of the great improvement in pain and the fact that the majority of patients regained the ability to engage in daily activities, we believe that this treatment is useful for complex fractures of the humerus