The aim of this retrospective and mono centric study is to expose results and complications of the reverse concept in the elderly in case of trauma. We therefore ask whether clinically the patients recover a pre-broken state, whether the radiological follow-up shows critical images and whether the rate of complications is important.

We reviewed the outcome of forty-two patients operated consecutively by the same surgeon at a mean follow-up of 9.1 years (range, 1–19 years). There were four men and thirty-eight females, mean age 75 (range, 58–92 years), with 28 complex four-part fractures and 14 fracture-dislocations. There was no re-fixation of the tubercles because of a poor bone quality.

Six complications occurred: 2 complex sympathetic dystrophies treated by medication, 2 early dislocations (one superior because of an impingement in adduction between the humeral stem and the remnants of the tubercles solved by their ablation without further problems and one anterior caused by the voluntary 10° ante-version of the humeral component to improve internal rotation leading to the reorientation of the stem), 1 deep infection solved by debridement and drainage for an early postoperative Acinetobacter infection without further problems and one aseptic loosening of the base-plate with a broken screw and no wear at 12-year follow-up leading to implant a classic base-plate because of a fair bone stock and efficient primary grip after impaction.

The mean Constant score dropped from 55 at one year to 52 (20 to 84) at last revision which represented 67% of the mean score for the injured side. Mean adjusted Constant score was 68. Only 58% of the patients were satisfied or very satisfied because of poor rotations avoiding nourishment with utensils, dressing andpersonal hygiene. When the dominant arm was affected, the patients lost frequently their autonomy.

Two patients with 42-mm glenospheres had complete 2-mm radiolucent lines at four- and eight-year follow-up. Inferior spurs were seen in 15 cases (35%). They were stable after emergence without functional impact or radiographic evolution. They appeared at a mean of 2.5 years (range, 1–6 years). Scapular notching was seen in 23 cases (55% of the patients), all appeared before two-year follow-up. Eleven notches were stable with a sclerotic border and without critical humeral images. Twelve were progressive with a proximal humeral bone loss (n = 7) or a radiolucent line (n = 5). In these cases, there was a negative effect on the Constant score: 41 points instead of 57 for notches without critical images.

Our experience reported in the present study has somewhat weakened our enthusiasm for this procedure. 42% of the patients were unsatisfied because of poor rotations and the functional results were never equal to the pre-injury state. 33% of the radiological images found were critical. 14% of the patients had a severe complication. Such results do not allow us to validate in the long-term the concept of RSA in recent trauma of proximal humerus. So nowadays, our elective indication is a woman for a non-dominant arm, over seventy years old with poor physiology and important osteoporosis.

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.

The aim of this retrospective study is to expose results and complications of the reverse concept in trauma. We therefore ask whether clinically the patients recover a pre-broken state, whether the radiological follow-up show worrisome images and whether the rate of complications is important.

We reviewed thirty-seven consecutive patients with 26 three- and four-part fractures and 11 fracture-dislocations, mean age 75 (range, 58–92 years) with a minimum follow-up of one year (mean, 7.3 years; range, 1–17 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 score dropped from 55 at one year to 52 (20 to 84) at last revision which represented 67% of the mean score for the injured side. Mean adjusted Constant score was 68. 42% of the patients considered the results to be unsatisfactory because of poor rotations avoiding nourishment with utensils, dressing and personal hygiene when the dominant extremity was involved.

We observed two complete borders between the base plate and the glenoid, fourteen stable inferior spurs which did not affect function and twenty-one inferior scapular notches including ten of them with medial proximal humeral bone loss or radio lucent lines between the cement border and the humerus. Notching increased in size with longer follow-up. Notching, accompanied by changes in proximal humerus, was associated with the weakest mean Constant score (41).

The functional results were not equal to the pre-injury state. When the dominant arm was affected, the patients lost frequently their autonomy. 60% of the radiological images found were worrying. 22% of the patients had a severe complication. New developments in design, bearing surfaces and surgical technique and long term studies may support the role of the reverse concept for fracture.

Synthesis and hemi-prosthesis give well known radiological results for acute proximal complex humeral fractures in elderly population. We wanted to expose the radiological outcome of the reverse concept in this indication.

From 1993 to 2008, forty four DELTA III were implanted for thirty three three-part and four-part displacements and eleven fracture-dislocations, in 3 males for 41 females, with an average age of seventy five years. The results were estimated with AP and LAMY profile Xrays.

Because of ten deceases and three moving, thirty one cases were reviewed with a mean follow-up of 6.3 years, range 1 to 15. The radiographs showed : two 2-mm thick borders on the glenoid at four and eight years with a scapular notch at 11 years and an aseptic loosening of the base plate at 12 years with a broken polar inferior screw. The patient underwent an easy surgical revision because of a fair bone stock. There was no wear of the polyethylene.

According to the NEROT classification, nineteen inferior scapular notches were observed with a mean occurrence time of 4.6 years. The seven type-1 notches appeared at a mean of 2 years and the five type-2 notches at a mean of 4.3 years. We observed four type-3 notches which reached the inferior screw at 5,6,7 and 8 years, and three type-4 notches which extended beyond the inferior screw at 6,7 and 8 year follow-up, respectively. There seem to be two distinct patters of notches: mechanical, stable proximal humeral bone loss because of an impingement between the humeral component and the inferior scapular pillar and biological, progressive in size, evolving over time with proximal humeral bone loss because of polyethylene disease; the longer the follow-up, the more severe the notch. Fourteen inferior spurs, stable after emergence, were reported with a mean occurrence time of 2.5 years range 1 to 6 years. One joint ossification occurred at 6 months and was stable at 6 year follow-up. The humeral results consisted in five medial (5,6,710, and 11 years) proximal bone looses and three bone-cement interface medial borders on the two thirds of the height of the stem at a mean follow-up of 5 years. In these eight cases, there was a notch associated. We reported one case of septic humeral loosening at 2 year follow-up.

For acute proximal humeral complex fractures in elderly population, when re-fixation of the tubercles on the classical orthopaedics devices is impossible, the use of a DELTA III prosthesis shows, with a mean follow-up of 6.3 years, worrying images in 70% of the cases.

These images are on the glenoid in 70% of the cases, appeared before seven years in 86% and are progressive in 50% of the cases. But, we have only one re-intervention for an aseptic loosening of the base plate at a twelve year evolution. New developments in design and bearing surfaces and a more long term results will probably provide more durable utilization of the reverse concept in this indication.

From 1993 to 2008, 44 DELTA III prostheses were implanted for 33 three-part and four-part displacements and 11 fracture-dislocations, in 3 males for 41 females, with an average age of seventy five years. The results were estimated with AP and profile X-rays.

Ten patients died and and three moved. Thirty one cases were reviewed with a mean follow-up of 6.3 years, range 1 to 15. The radiographs showed:

two 2-mm thick borders on the glenoid at four and eight years.

In elderly patients with trauma, when attachment of the tubercles on the classical orthopaedics devices is impossible, the use of a RSA leads to precocious worrying and progressive images but with only one re-intervention for an aseptic loosening of the base plate at a twelve year evolution. New developments in design and bearing surfaces, new surgical techniques of implantation and a more long term results will probably provide more durable utilization of the reverse concept for this indication.

Synthesis and hemi-prosthesis give well known radiological results for acute proximal complex humeral fractures in elderly population. We wanted to expose the radiological outcome of the reverse concept in this indication.

From 1993 to 2007, forty one DELTA III were implanted for thirty two three-part and four-part displacements and nine fracture-dislocations, in 3 males for 38 females, with an average age of seventy five years. The results were estimated with AP and LAMY profile X-rays.

Because of nine deceases and two moving, thirty cases were reviewed with a mean follow-up of 6.5 years, range 1 to 14. The radiographs showed: two 2-mm thick borders on the glenoid at four and eight years with a scapular notch at 11 years and an aseptic loosening of the base plate at 12 years with a broken polar inferior screw. The patient underwent an easy surgical revision because of a fair bone stock. There was no wear of the polyethylene. According to the NEROT classification, seventeen inferior scapular notches were observed with a mean occurrence time of 4.7 years. The seven type-1 notches appeared at a mean of 2 years and the five type-2 notches at a mean of 4.3 years. We observed three type-3 notches which reached the inferior screw at 5,6 and 7 years, and two type-4 notches which extended beyond the inferior screw at 6 and 7 years follow-up, respectively. There seem to be two distinct patters of notches: mechanical, stable proximal humeral bone loss because of an impingement between the humeral component and the inferior scapular pillar and biological, progressive in size, evolving over time with proximal humeral bone loss because of polyethylene disease; the longer the follow-up, the more severe the notch. Fourteen inferior spurs, stable after emergence, were reported with a mean occurrence time of 2.5 years range 1 to 6 years. One joint ossification occurred at 6 months and was stable at 6 year follow-up. The humeral results consisted in four medial (5,6,7 and 10 years) proximal bone looses and two bone-cement interface medial borders on the two thirds of the height of the stem at 5 year follow-up. In these six cases, there was a notch associated. We reported one case of septic humeral loosening at 2 year follow-up.

For acute proximal humeral complex fractures in elderly population, when re-fixation of the tubercles on the classical orthopaedics devices is impossible, the use of a DELTA III prosthesis shows, with a mean follow-up of 6.5 years, worrying images in 70% of the cases. These images are on the glenoid in 70% of the cases, appeared before seven years in 86% and are progressive in 50% of the cases. But, we have only one re-intervention for an aseptic loosening of the base plate at a twelve year evolution. New developments in design and bearing surfaces and a more long term results will probably provide more durable utilization of the reverse concept in this indication.

Purpose of the study: Hemi-arthroplasty, osteosynthesis, and ball-and-socket implants provide well-known results for the management of displaced joint fractures of the proximal humerus in elderly subjects. The purpose of this work was to assess the reversed Grammont prosthesis for these indications.

Material and methods: From 1993 to 1999, eighteen Delta III prostheses were implanted by the same operator in recent trauma victims. The patients, 17 women and one man, mean age 75 years, presented four-fragment fractures (n=15) or fracture dislocation (n=3). The dominant side was involved in nine cases. These patients presented infiltrative rotator cuff tendinopathy (n=4), type 1 diabetes mellitus (n=2), exogenosis (n=2), morbid obestity (n=2), homelessness (n=2), and dementia (n=2). Surgery was performed under general anesthesia in the semi-sitting position via a trapezodeltoid approach without acromion osteotomy and with 20° humeral implant retroversion in all cases except one, cemented in 17 cases. The tubercles could be reinserted in four patients. Rehabilitation was not always possible. The Constant score and the anteroposterior and Lamy lateral views were used to assess clinical and radiographic outcome.

Results: There were two deaths, so the analysis included 16 shoulders. Complications were: shoulder-hand syndrome (n=1), early deep Acinetobacter infection with revision and preservation of the arthroplasty (n=1), anterior dislocation at one month due to voluntary 10° anterotation of the humeral stem requiring reorientation (n=1). At mean follow-up of 85 months, the Constant score was 60, with a weighted score of 83%. The results were not influenced by reinsertion of the tubercles and were considered good for pain and activity, fair for strength, and disappointing for rotations. The x-rays did not reveal any sign of humeral loosening. There was one lucent line between the glenoid and the metaglenoid, four cases with pillar notches, and nine infraglenoid ossifications.

Discussion and conclusion: For displaced joint fractures of the proximal humerus, endomedullary osteosynthesis and the ball-and-socket implant have shown their efficacy as an alternative to hemiarthroplasty. The reverted prosthesis also appears to be a valid therapeutic option for elderly persons with osteoporotic bone compromising the reinsertion of the tubercules. This option enables good results for pain, activity, strenth and active mobility except for rotation, with only five signs of gravity for the glenoid with one involving the glenoid and none the humerus at 85 months follow-up. These results should be further confirmed with a larger series and longer follow-up.