Abstract. Background. Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients. Objectives. To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. Study Design & Methods. All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre – existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. Results. Union was achieved in all the 37 patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70 degrees of abduction and forward flexion. We had 29 excellent, 6 good, 2 fair and none poor results as per Constant scoring system. Study done in Tejasvini Hospital & SSIOT Mangaluru India

Purpose

Locking plates are widely used in clinical practice for the surgical treatment of complex proximal humerus fractures, especially in osteoporotic bone. The aim of this study is to assess the biomechanical influence of the infero-medial locking screws on maintaining reduction of the fragments in a proximal humerus fracture.

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Aim. A significant number of patients undergoing shoulder arthroplasty surgery have C acnes contamination at the end of the primary surgery. The objective of this study is to determine whether patients with C acnes contamination at the end of their primary shoulder surgery have a worse prognosis than those who end up without C. acnes contamination. Method. Prospective study including all patients who underwent a reverse shoulder prosthesis from January 2015 to December 2018. In all of them, 5 to 12 cultures were performed during primary surgery. The patients underwent surgery for shoulder arthritis secondary to rotator cuff tears, acute fracture of the proximal humerus, and sequelae of fracture of the proximal humerus. Exclusion criteria included the existence of previous surgeries on the affected shoulder, the presence of signs of infection, having received infiltrations and / or complementary invasive examinations (Arthro-MRI and Arthro-CT). Follow-up from 2 to 5 years. Functional assessment according to the Constant Functional Scale. All complications were also recorded. Results. 162 patients were included. Of these, 25 had positive cultures for C. acnes at the end of primary shoulder surgery. Average age of 74.8 years. 136 women and 26 men. 75.9% Shoulder arthritis secondary to rotator cuff tears, 13.6% acute fractures and 10.5% sequelae of fractures. There were no differences between patients with C. acnes and those without C. acnes regarding age and indication for surgery. Predominance of men in the group with positive C. acnes (p <0.001). No differences at 2 and 5 years in the Constant functional scale between the two groups (2 years, 59.6 vs 59.2 p 0.870) (5 years, 62.4 vs 59.5 p 0.360). Significant differences regarding the number of complications (p 0.001). Patients without C. acnes had 1 aseptic loosening of the metaglene and patients with C. acnes had 2 infections, 1 dislocation, and 1 revision surgery. Patients with contamination by C. acnes had more comorbidities (p 0.035) than patients without contamination. Conclusions. Patients with C acnes contamination at the end of primary surgery do not have functional differences when compared with patients without contamination at 2 and 5 years, but they have a higher number of complications in the medium term

Surgeries for reverse total shoulder arthroplasty (RTSA) significantly increased in the last ten years. Initially developed to treat patients with cuff tear arthropathy (CTA) and pseudoparalysis, wider indications for RTSA were described, especially complex proximal humerus fractures. We previously demonstrated in patients with CTA a different sequence of muscular activation than in normal shoulder, with a decrease in deltoid activation, a significant increase of upper trapezius activation and slight utility of the latissimus dorsi. There is no biomechanical study describing the muscular activity in patients with RTSA for fractures. The aim of this work is to describe the in vivo action of RTSA in patients with complex fractures of the proximal humerus. We conducted an observational prospective cohort study comparing 9 patients with RTSA for complex humerus fracture (surgery more than 6 months, healed tuberosities and rehabilitation process achieved) and 10 controls with normal shoulder function. Assessment consisted in a synchronized analysis of range of motion (ROM) and muscular activity on electromyography (EMG) with the use of 7 bipolar cutaneous electrodes, 38 reflective markers and 8 motion-recording cameras. Electromyographic results were standardized and presented in muscular activity (RMS) adjusted with maximal isometric contractions according to the direction tested. Five basic movements were evaluated (flexion, abduction, neutral external rotation, external rotation in 90° of abduction and internal rotation in 90° of abduction). Student t-test were used for comparative descriptive analysis (p < 0,05). The overall range of motion with RTSA is very good, but lower than the control group: flexion 155.6 ± 10 vs 172.2 ± 13.9, p<0.05, external rotation at 90° 55.6 ± 25 vs 85.6 ± 8.8, p<0,05, internal rotation at 90° 37.8 ± 15.6 vs 52.2 ± 12, p<0,05. The three heads of the deltoid are more stressed during flexion and abduction in the RTSA group (p. The increased use of the 3 deltoid chiefs does not support the hypothesis proposed by Grammont when the RTSA is performed for a complex proximal humerus fracture. This can be explained by the reduced dispalcement of the rotation center of the shoulder in these patients compared to those with CTA. These patients also didn't present shoulder stiffness before the fracture. The maximal muscle activity of the trapezius in flexion and of the latissimus dorsi in flexion and abduction had not been described to date. These new findings will help develop better targeted rehabilitation programs. In addition, the significant role of the latissimus dorsi must question the risks of its transfer (L'Episcopo procedure) to compensate for external rotation deficits

Management of 4-part fractures of the proximal humerus continues to challenge orthopaedic surgeons, shoulder surgeons, and trauma surgeons. Truly displaced 4-part fractures typically require surgery if the patient is medically able to undergo a surgical procedure. However, outcomes following surgery are not always as predictable as we would like. Results following hemiarthroplasty have led to more predictable pain relief than predictable functional recovery relying exclusively on the fate of tuberosity healing. Tuberosity healing failure leads to nearly universal catastrophic results with pain, dysfunction, and pseudoparalysis. Furthermore, conversion of failed hemiarthroplasty to reverse total shoulder arthroplasty leads to the highest incidence of complications and poorest outcomes of all groups of patients undergoing reverse total shoulder replacement. This is countered by the knowledge that if tuberosity healing occurs the outcome can be reliable with regard to pain relief and functional restoration. Reverse total shoulder arthroplasty, on the other hand, has emerged as a preferred surgical option for many surgeons due to the issues following hemiarthroplasty. The increased prevalence of RTSA for the management of 4-part fractures has come without overwhelming evidence that outcomes are superior especially in light of the increased cost, life-time weight bearing restrictions, and uncertain long-term durability. Long-term follow-up of patients treated with RTSA for 4-part fracture has shown concerning degradation of function and outcomes and remains a valid concern about the long-term durability. We must remain diligent therefore in continuing to better understand which fractures should be treated non-operatively and those that may be amenable to anatomic hemiarthroplasty and finally those which may be better served by using a reverse total shoulder replacement

The primary objective of this study was to determine if paediatric proximal humerus fractures undergo significant displacement resulting in change in management. A retrospective analysis was performed on children who presented with proximal humeral fractures to our institution between 2009 and 2014. Patients were included if they were diagnosed with a fracture of the proximal humerus in the absence of an underlying bone cyst or pathological condition. Patients with open fractures, multiple fractures, neurologic, or vascular injuries were excluded. The primary endpoint was conversion to operative treatment after initial non-operative management. Secondary endpoints were a healed fracture with acceptable alignment at the final radiographic evaluation, as well as the number of follow-up radiographs obtained after the initiation of non-operative management. A decision to manage the fracture operatively at the initial presentation was made in 14 out of 239 patients. Of the 225 patients that were initially managed non-operatively, only 1 patient underwent subsequent surgical management. In this series, no non-unions, re-fractures, nor fracture-dislocations were identified. These data support that the majority of management decisions for paediatric proximal humeral fractures are made at the initial presentation. Once non-operative management is chosen, routine follow-up imaging rarely leads to any change in treatment

Displaced two- to four-part fractures of the proximal humerus pose a difficult therapeutic challenge. We report the results of internal fixation of these fractures in a case series of 50 patients with a locking plate system. All fractures united with no failure of fixation. The mean constant score was 79. One patient developed avascular necrosis. Internal fixation with locking plate system in healthy active patients, disregarding their age, is a reliable method of treating displaced proximal humerus fractures. The tuberosities should be restored anatomically prior to plate application. Surgical expertise in treating shoulder conditions is essential for good functional outcome

Contoured locking plates are commonly used to fix the proximal humerus fractures. Their long-term results are unknown. We present long-term radiological and functional outcome of three and four part fractures of the proximal humerus treated with PHILOS plate. We prospectively analysed 53 consecutive three and four part proximal humerus fractures treated with PHILOS plate between 2002 and 2007. Patients were assessed using Oxford Shoulder Score and DASH score. 44 fractures (21 three part and 23 four part) were available at the final follow up. At a mean follow-up of 8.5 years (6.4 years–10.8 years) the average Oxford Shoulder Score was 43.9 (range 23–48) and the average DASH score was 7.7 (range 0–36.7). 30% of patients required re-operation (five for hemiarthroplasty, three for impingement syndrome, five for removal of implant). Avascular necrosis (AVN) developed in 10 patients, of which only three required hemiarthroplasty. All except one patient were satisfied with the result of their operation. Our study supports the use of locking plates for the treatment of three and four part proximal humeral fractures. In spite of some patients requiring secondary surgical intervention in the first few years, the function of the shoulder continues to improve and in the long term patients were satisfied with the outcome. An important finding of our study is that the post-traumatic AVN of humeral head does not necessarily need major surgical intervention. We believe that the possibility of avascular necrosis should not be a major determinant in the choice of surgical treatment of proximal humeral fractures

Whilst the use of reverse total shoulder arthroplasty is becoming more common for the treatment of rotator cuff arthropathy, there is still relatively little evidence with regards to its use in complex fractures of the proximal humerus in the elderly. It is increasingly felt to be of use in those patients in whom either internal fixation is not possible due to fracture configuration or bone quality, or in whom there is a rotator cuff deficiency. We report the outcomes of 14 patients with complex 3- or 4-part humeral fractures or delayed presentation of dislocation treated with reverse TSR. Patients were treated within a two year period from January 2011 to December 2013. The average age at time of operation was 75 (50–91 years) with a mean follow-up of 7 months (2–13 months). One patient moved out of area and one lost to follow-up two months following procedure. Reverse TSR was considered a salvage procedure for patients with comminuted proximal humeral fractures or those who presented with irreducible non-acute dislocations. At time of last follow-up all 14 patients were satisfied with the results of their operation and functionally independent with activities of daily living. Range of movement post-operatively was good with mean active forward extension 97° (70–150°) and abduction 101° (80–170°). 43% of patients were pain-free, whilst the remainder only required the use of occasional analgesia. No major post-operative complications were reported. Patients who underwent reverse TSR for dislocation fared better than for those with proximal humeral fractures. The mean active forward extension was 107.5° (90–150°) and abduction 112.5° (90–170°) in the dislocation group (n=5) compared with those who had a fracture in which the forward extension was 91.4° (70–120°) and abduction 95° (80–120°). The results of these patients demonstrate that reverse TSR should be considered in patients with complex proximal humeral fractures or delayed presentation of fractures. It seems to provide consistently excellent pain-relief for patients, with patients either reporting being pain-free or requiring only occasional analgesia. In addition, all patients treated were functionally independent following operation. Range of movement, particularly for those with dislocation, appear good. Further follow-up is required to ensure sustained results but early studies are encouraging

Introduction:. Tuberosity healing is strongly correlated with functional results in all series of three- and four-part fractures of the proximal humerus treated by hemiarthroplasty. We formed a working group to improve position of the implant and fixation of the tuberosities on an implant specifically intended for traumatology. Material and Methods:. An anatomic study on 11 cadavers and a prospective multicentre clinical study of 32 cases were performed to validate extrapolable original solutions at the patient scale: placement of the stem at a height indicated in relation to the insertion of the clavicular bundle of the pectoralis major, locking of the stem, placement (based on bone quality) of a variable volume metaphyseal frame (offset modular system® OMS®), avoiding medialisation of the tuberosities, and fixation of the tuberosities using strong looped sutures, brightly coloured so that they can be located more easily. Evaluation by Dash score and Constant score was correlated with positioning of the tuberosities using radiographs. Results:. The clinical study enabled a distance of the top of the head to pectoralis major of 5.5 cm +/− 5 mm to be determined, confirming the results of the anatomic study and data from the literature. The distal double-locking ancillary device and the suturing technique for the tuberosities using looped sutures was judged to be effective by all of the surgeons. 23 patients (5 males, 9 CT4 and 8 CT3) with an mean age 69,6 (33–90) were operated on by 3 senior surgeons and reviewed at a mean follow-up of 17,3 months (6–24). All patients were seen again at 3 months and 6 months and the average motion at last follow was abduction of 90,7° (140–40), active anterior elevation of 113,25° (160–60), and external rotation of 43,2°(55–30). One complication was noted: inadequate position of a locking screw. In the 17 patients operated without oms® 50% had adequate initial positioning of the tuberosities and 10% secondary displacement. In comparison the 6 patients operated with the oms® 100% had adequate initial positioning of the tuberosities and no secondary displacement occurred. Discussion:. The series from Sofcot, Boileau, and more recently Reuther yielded results of 40 to 66% malposition or nonunion of the tuberosities. The initial clinical results from our series are encouraging and demonstrate that using a variable volume metaphyseal frame in synthesis of the tuberosities with control of the height of the implant is reliable. This multicentre study should be extended by a more long-term analysis

Aims

Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this.

We present a series of 18 consecutive cases of primary reverse total shoulder arthroplasty for irreparable proximal humerus fractures in patients over 70. Failure of tuberosity union and poor cuff function leads to unsatisfactory results in over half the patients with hemiarthroplasty. Reverse total shoulder arthroplasty does not depend upon a functional rotator cuff and requires little formal rehabilitation. Patients over 70 with irreparable proximal humerus fractures treated with a reverse total shoulder arthroplasty were included in this study. Only primary arthroplasties were included. Reverse arthroplasties for failed hemiarthroplasties were excluded. All arthroplasties were performed using either a deltoid split direct lateral (superior) approach or the antero-lateral MacKenzie approach. The SMR reverse total shoulder prothesis was implanted in all cases using a press-fit glenoid base plate and glenosphere, and press-fit or cemented humerus stem. Tuberosity repair was attempted in 10 cases. The supraspinatus was excised from the greater tuberosity. Patients were allowed self-mobilisation after two weeks in a sling. Patients were recruited and followed up per ethics approved protocol. Outcome measures used were range of motion, dislocation and revision rates radiological signs of loosening and glenoid notching, DASH and Constant scores. Results were compared to another series of cases of reverse shoulder arthroplasty for sequelae of trauma and failed hemiarthroplasties, as well as a series of primary hemiarthroplasties. At an average follow-up of 30 months (minimum 12 months) all patients were satisfied with their results. Average forward elevation was 132 deg. and abduction 108 deg. There was not deterioration of movement at 12 or 24 months. No patient had ongoing pain. The average constant score was 62. There was no evidence of humeral stem loosening apart from one case of early subsidence in a press fit stem. Eleven cases showed glenoid notching, four Nerot grade 1, six Nerot grade 2 and one Nerot grade 3. All notching had stabilised after 12 months. There were no cases of dislocation. No case needed revision, or awaits revision. All cases were pain-free at last review. Overall results for this group of primary reverse arthroplasties for fractures was much better than for reverse arthroplasties for sequelae of trauma. The results were also better than for primary hemiarthroplasties. Irreparable three and four part fractures of the proximal humerus pose management challenges in the elderly. The reverse total shoulder arthroplasty is very attractive option for elderly patients with irreparable proximal humerus fractures. They require little rehabilitation and can give reproducibly good functional results, which do not deteriorate with time

Purpose. To evaluate the results of reverse total shoulder arthroplasty for complicated proximal humerus fractures in old ages. Materials and Methods. We retrospectively evaluated 13 cases who underwent reverse total shoulder arthroplasty for proximal humerus fracture, fracture-dislocation and nonunions of the fractures. Mean age was 77(68–87)years old and mean follow-up period was 15.2(12–26)months. four part fractures of proximal humerus in 7 cases, fracture-dislocation in 3 cases, locked dislocation with greater tuberosity in 2 cases, nonunion with defiency of rotator cuff in 1 case were included. We evaluated mean ASES, mean UCLA, mean KSS, mean SST and mean range of motion(ROM). Results. Postoperative mean ASES was 59(13–98.5), mean UCLA was 21(12–34), mean KSS was 62(21–94), mean SST was 5(1–11). Postoperative mean ROM was 103°(30°–135°) in forward flexion, 93°(30°–135°) in abduction, 21°(0°–45°) in external rotation and L4 level in internal rotation. The complications were not shown in any cases except for resolved heterotropic ossification. 4 cases demonstrated bony unions on greater tuberosity and 4 cases showed scapular notching on last follow-up. Conclusions. Reverse total shoulder arthroplasty for complicated proximal humerus fracture, nonunion of the fracture, or chronic locked dislocation seems to be a good treatment options. Regardless of bony union of the greater tuberosity, reverse total shoulder arthroplasty for the complicated proximal humerus fractures had a satisfied results

Purpose:. To evaluate the results of reverse total shoulder arthroplasty for complicated proximal humerus fractures in old ages. Materials and Methods:. We retrospectively evaluated 13 cases who underwent reverse total shoulder arthroplasty for proximal humerus fracture, fracture-dislocation and nonunions of the fractures. Mean age was 77 years old and mean follow-up period was 15.2(12–26) months. four part fractures of proximal humerus in 7 cases, fracture-dislocation in 3 cases, locked dislocation with greater tuberosity in 2 cases, nonunion with defiency of rotator cuff in 1 case were included (Fig. 1, Fig. 2, Fig. 3). We evaluated mean ASES, mean UCLA, mean KSS, mean SST and mean range of motion (ROM). Results:. Postoperative mean ASES was 59(13–98.5), mean UCLA was 21(12–34), mean KSS was 62(21–94), mean SST was 5(1–11). Postoperative mean ROM was 103° in forward flexion, 93° in abduction, 21° in external rotation and L4 level in internal rotation. 4 cases demonstrated bony unions on greater tuberosity and 4 cases showed scapular notching on last follow-up. Conclusion:. Reverse total shoulder arthroplasty for complicated proximal humerus fracture, nonunion of the fracture, or chronic locked dislocation seems to be a good treatment options. Regardless of bony union of the greater tuberosity, reverse total shoulder arthroplasty for the complicated proximal humerus fractures had a satisfied results. Key words: Shoulder, Proximal humerus fracture, Reverse total shoulder arthroplasty

Background. The procedures of total elbow and shoulder replacements increased 6% to 13% annually from 1993 to 2007 with revision-related burden increasing from 4.5% to 7%. The revisions of the shoulder and elbow prostheses due to aseptic loosening, periprosthetic fractures, infections have led to the use of standard or custom-made implants due to significant bone loss. This study reports our experience in the management of complicated primary and revisions of total shoulder and elbow replacements with significant humeral bone loss and in metabolic diseases of the elbow and shoulder treated with bone resection using The Mosaic Humeral Replacement System. Patients and Materials. A total of 20 patients underwent total elbow or shoulder arthroplasty using the Mosaic Humeral Replacement System (Biomet, UK). The Mosaic system was used in 8 shoulder arthroplasties (Group A) and in 12 elbow arthroplasties (Group B). The underlying pathologis in Group A included 2 malunited proximal humerus fracture, 1 humeral osteomyelitis, 1 shoulder chondrosarcoma, 1 aggressive Gigantic Cell Tumor with prosthetic fracture, 2 metastatic lytic lesion, and 1 failed fixation of non-union proximal humerus. Figure 1 shows Mosaic implant after complex fracture of proximal humerus. Reasons for Mosaic arthroplasty in Group B included 3 humeral component revisions due to periprosthetic fracture, 1 prosthesis breaking-up with fractures, 1 revision of loose Souter Strathclyde prosthesis, 1 loose prosthesis due to infection, 1 highly comminuted elbow fracture, 1 aseptic loosening of humeral component of total elbow replacement, 3 revision of total elbow replacement due loosening and 1 pathological distal humerus fracture due to metastasis. Figure 2&3 shows pre- and post-operative Mosaic implant following complex periprosthetic fracture of distal humerus. Clinical Observation/Discussion. The Mosaic Humeral Replacement System is a complete system for complex revision, salvage/oncology, and complex humeral fractures. It is a completely modular system which can be adapted to different patient anatomies and indications. It has been designed to face several surgical challenges, including reattaching soft tissues, properly tensioning the glenohumeral joint and restoring joint function. It is a cost-effective procedure with the benefits of a custom made humeral component in a standard tray. Our study shows that good results can be achieved with this form of treatment. Radiological assessment of all patients showed a satisfactory position of the implant with appropriate margin of bony resection. One patient with proximal and another one with distal humeral Mosaic replacement had late infection. One patient had aseptic loosening 3 years after distal humeral replacement. Most of the patients had satisfactory improvement in range of movement and chronic pain. While primary clinical observations and imaging results indicate acceptable results with Mosaic arthroplasty; a realistic assessment can only be achieved in long-term using the appropriate outcome measures. At the present we continue to regularly assess the patients clinically and radiologically and by means of Liverpool elbow score for distal and Quick- DASH for proximal Mosaic Humeral Replacement System and plan to report the long-term results in due time

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.