Introduction: The three or four-part fracture of the proximal humerus remains a challenging fracture in the case of elderly patient. In this continuing prospective study we compared the outcome after implantation of a shoulder hemiprosthesis of the anatomical generation and a reversed prosthesis.

Material and methods: 34 shoulder prosthesis were implanted in patients older than 70 between june 1996 and june 2004. All patients were evaluated by a surgeon not involved in treatment concerning activities of daily living (DASH scoring), clinical outcome (Constant-Murley Score), radiological results, and a summary of complications.

Group 1: anatomical prosthesis (Tornier): At an average follow-up of 16,5 (range 6–55) months, 13/17 patients with an average age of 78,6 years (70–95), were evaluated.

Group 2: reversed prosthesis (Depuy): At an average follow-up of 12,6 (range 6–18) months, 13/17 patients with an average age of 77,1 years (70–84), were evaluated. In this group functional treatment was started immediately after surgery.

Results: concerning age, follow up and dash scoring there were no difference between two groups. In reversed group : the outcome was better (Constant-Murley: 79,5 (57,8–100) vs 57,1 (21–85) p=0.005), the average active elevation was better by 30° (p< 0.001) and the average active abduction was better by 53° (p< 0.001). 7/13 cases of glenoid notching stage 2 or 3 were noted. In anatomical group : the average active external rotation was better by 10° (p=0.01). Tubercle fixations failed in 6/13 cases.

Discussion: No comparative study has still been published between the two sort of implant in elderly patients. Our results of shoulder arthroplasty in acute injury to the proximal humerus with reversed prosthesis are in agreement with the preliminary results reported by Sirveau. At short follow up, reversed prosthesis allow to reach early mobilisation with best functional results. Rotation remains the key point : with a significant gain in active abduction and elevation the reversed prosthesis group do not reach a better dash scoring. Attachment fixation of the posterior rotator cuff must probably be discussed in reversed prosthesis in acute fracture.

Objective: 6 cases of postraumatic arthritis of the distal radius treated by chondro costal graft are reported with a minimum follow up of 2 years

Material and methods: 6 patients (One 22 years old patient with a dislocated radiocarpal joint 6 months after an injury, 3 patients (48, 52 and 53 years old) respectively 1, 1,5 and 2 years after a intraarticular fracture of distal radius and a patient (74 years old) with radio lunate arthritis reported two mains complaints : pain and stiffness. The last patient was a female with a destruction of radio scaphoid joint after septic complication of scaphoid surgery. Location of the cartilage defect was central in two cases and palmar in the others. A dorsal approach in one case, a palmar approach in the five others allowed reduction and reconstruction of the destroyed radial part of joint. An osteochondro costal graft harvested on the eight’s rib was inserted and fixed by plate in place of the articular impaction. Plaster cast of 3 months in the first case and 1 month in the others cases followed the articular reconstruction

Results : No complication have been pointed. Union was achieved in all 6 cases. Integration and viability of the graft were evaluated with RMI. At the highest follow up functionnal result are excellent in the youngest first case (male, 22 years old) where motion and grasp are similar than the controlateral side. In the 4 others cases of mal union patients were pain free in daily activity with a functionnal wrist score of 72/100 (54–82) and a DASH of 38,3 (22,5–51,7). Only the case with the septic problem failed with pain at follow up.

Conclusion: Reconstruction of a partially destroyed articular surface by a costal graft is reliable and allows filling and resurfacing an articular cartilage void. If chondro costal graft is currently used in maxillo facial surgery it is the first report in post traumatic arthritis secondary to intra articular mal union.

Purpose of the study: Functional recovery afte displaced cephalotuberosity fracture of the proximal humerus in pateints aged over 70 years is a major surgical challenge. Reconstuction with an inversed prosthesis avoids the problems of tuberosity fixation. We report a prospective consecutive series of reversed prostheses used of 3 and 4 fragment displaced and non-displace fractures in patients aged over 70 years.

Material and methods: Between January 2001 and June 2004, 19 patients aged over 70 years were included in this study, 16 women and 3 men, mean age 74.9 years (range 58–94 years, median 76 years). All presented 3- or 4-fragment fractures. An independent operator established the Constant and Dash scores. The position of the implants, loosening, presence of a glenoid notch (Nerot) were noted on plain x-rays.

Results: Sixteen of the 19 patients (13 women, 3 men), mean age 73.9 years (range 58–94 years) were reviewed at mean 12.6 months follow-up (range 6–18 months). There were no cases of dislocation. Hematogenous sepsis occurred at 16 months in one patient and led to implant removal. The raw Constant score was 53 (34–76) and the weighted Constant score 76.1 (41–110.1). The Dash score was 37.4 (34–76). Active abduction reached 91.2° (10–150°), active elevation 97.5° (20–150°), active RE1 6.6° (0–50°), active RE2 9.4° (0–90°) and active internal rotation 31.2° (0–60°). There was a humeral lucent line in five cases and a grade 0 glenoid line in one, grade 1 and 2 in six, and grade 3 in three.

Discussion: The only series of fracture of the proximal humerus in patients aged over 70 years was a retrospective study of prosthesis patients reported by Wretenberg in 1997. To date, there has not been a published series on use of the reversed prosthesis for fracture. For the short term in a population with frail bone and minimal functional requirements, reversed implants provide the best subjective and objective functional results. The absence of postoperative immobilization and independence from the rotator cuff enables rapid recovery of useful motion. Range of motion is reduced only to a small extent for rotation. Thus when possible, we reinsert the tuberosities with the reversed implant. Even if the tuberosity assembly dismounts (agitation in a context of temporospatail disorientation), there is no consequence on the reversed prosthesis. The large number of lucent lines with no clinical impact is a point to be examined carefully, showing that further improvement can be achieved with the existing implants.