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.

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.