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25Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-34

Min W, Davidovitch RI, Tejwani NC. Three- and our-part proximal humerus ractures: evolution to operative care. Bull NYU Hosp Jt Dis. 2012;70(1):25-34.

Abstract

The recent increase in lie expectancy is expected to bring

about a concurrent rise in the number o proximal humerus

ractures. Those presenting with signifcant displacement,

osteoporosis, and comminution present distinct clinical

challenges, and the optimal treatment o these injuries re-

mains controversial. As implant technologies and treatment

strategies continue to evolve, the role and appropriateness

o certain operative and nonoperative treatment modalities

are being debated. Prior concerns regarding humeral head

viability orced many physicians to abandon operative

management in avor o nonoperative modalities. However,

with greater appreciation and understanding o the actors

governing humeral head viability, operative intervention isincreasingly used and investigated. Nevertheless, sub-opti-

mal results with earlier implants continue to cloud the debate

between nonoperative and operative treatment modalities.

This paper will review historical considerations, biologic

considerations, and implant considerations in the manage-

ment o three-and our-part proximal humerus ractures.

Proximal humerus ractures account or approximately

5% o all ractures and represent the third most

requent racture o the elderly.1 Most commonly

related to osteoporosis,2 these ractures are oten associ-

ated with elderly co-morbidities that increase their risk or

low-energy alls, such as medication, poor vision, and loss

o protective reexes. However, unlike many osteoporotic

ractures, proximal humerus ractures can also occur in the

ft elderly.3 Due to the anticipated increases in lie expec-

tancy, the number o elderly proximal humerus ractures is

expected to triple by 2030.4

A signifcant majority (85%) o these ractures are mini-

mally- or non-displaced4 and are generally treated nonopera-

tively.5 However, controversy exists regarding the optimum

treatment or displaced ractures. Treatment options range

rom nonoperative to operative modalities. Recent meta-

analyses and larger retrospective and prospective series

have not shown an advantage o one treatment modality

in the management o all displaced ractures.3,6-8 Adding to

this debate, newer implant technologies have challenged theconventional thinking regarding management o displaced

proximal humerus ractures. This paper, written in two parts,

will examine the evolution o treatment o proximal humerus

ractures, and the role that newer implant technologies have

played in changing this paradigm.

Nonoperative Management

As early as 180 AD, Galen described his treatment o

proximal humerus ractures and racture-dislocations.9 Ater

reduction by traction-countertraction methods, the extremity

was immobilized with a valgus mold.9 Because there were

no eective operative methods available, this was considered

the frst described orm o treatment or highly comminutedand unstable proximal humerus ractures. Subsequently, non-

operative management continued to serve as the treatment o

choice or highly comminuted or unstable proximal humerus

ractures, due to lack o eective surgical technologies and

concerns regarding humeral head viability.

Existing literature5,7,10-12 has generally supported nonoper-

ative management; however, while minimally displaced and

non-displaced ractures are preerentially and successully

treated using nonoperative methods with good results,5,7,10-12

Three-and Four-Part Proximal Humerus FracturesEvolution to Operative Care

William Min, M.D., M.S., M.B.A., Roy I. Davidovitch, M.D., and Nirmal C. Tejwani, M.D.

William Min, M.D., M.S., M.B.A., is in the Division o Orthopae-

dic Surgery, University o Alabama at Birmingham, Birmingham,

Alabama. Roy I. Davidovitch, M.D., and Nirmal C. Tejwani,

M.D., are in the Department o Orthopaedic Surgery, NYU

Hospital or Joint Diseases, New York, New York.

Correspondence: Nirmal C. Tejwani, M.D., Department o Or-

thopaedic Surgery, NYU Hospital or Joint Diseases, 301 East

17th Street, Suite 1402, New York, New York 10003; nirmal.

[email protected].



Bulletin o the NYU Hospital or Joint Diseases 2012;70(1):25-3426

the studies evaluating the role o nonoperative management

in severely comminuted proximal humerus ractures are

non-validated, non-randomized, and inconclusive.4

Zyto retrospectively investigated the clinical and radio-

graphic results o displaced three- and our-part displaced

ractures treated nonoperatively and ollowed or a minimum

o 10 years, and ound that, despite poor unctional scores

and non-anatomic reductions radiographically, all patientsreport high contentment with their outcomes.6 However,

Zyto’s recommendations or nonoperative treatment were

reserved or three-part ractures, as the our-part ractures

demonstrated more disability than the three-part group. Lill

examined the role o nonoperative management in two-

and three-part ractures and ound that over 60% o their

patients had good and excellent Constant scores. However,

similar to Zyto’s study,6 our-part ractures uniormly had

poor outcomes and poor Constant scores, mostly attributed

to avascular necrosis o the humeral head and resulting

arthrosis.13

Based on these indings and in light o our current

treatment strategies, nonoperative treatment or displaced

three- and our-part ractures is currently reserved or in-

dividuals who are medically contraindicated or surgery

or have low-demand liestyles where the risks o surgery

outweigh its benefts. While these studies suggest that non-

operative treatment is better suited or three-part ractures

(as compared to our-part racture), nonoperative treatment

in these highly displaced ractures may result in signifcant

unctional impairment, shoulder stiness, and malunion.14

Humeral Head Viability and the Evolution tothe Role of Operative Treatment

Despite the potential limitations o nonoperative manage-ment or highly displaced ractures, it was historically held

as the preerred treatment option due to concerns or humeral

head viability. Traditionally, nonoperative measures were

preerred since it was believed that operative management

may disrupt humeral head blood ow and accelerate avas-

cular necrosis.15 With the predominant blood supply o the

humeral head coming rom the arcuate artery (a branch

existing lateral to the bicipital groove and originating rom

the anterior humeral circumex artery), earlier surgical

techniques potentially had a higher risk o disrupting this

critical blood supply. This was evident in the higher rates

o avascular necrosis ater operative treatment o our-part

ractures seen in earlier series.16 However, Neer’s results were the frst to suggest that

nonoperative management o these ractures was a poorer

alternative than operative treatment.16 This fnding, coupled

with improved surgical techniques and implant options,

began to challenge the notion that operative treatment was a

poor option or displaced ractures. Additionally, improved

understanding regarding the actors and risks or humeral

head avascular necrosis lead to urther understanding and im-

proved racture management. While the association between

racture pattern and avascular necrosis rate has not yet been

clearly established,17 it is clear that poor surgical techniques

can increase the risk o avascular necrosis in three-part

ractures to that seen in our-part ractures.18 This urther

clarifes Neer’s original theory, where he believed that three-

part ractures did poorly due to poor surgical technique and

inadequate reductions while our-part ractures did poorly

due to avascular necrosis.16 While Neer’s original theoryhad led him to recommend operative fxation or three-part

ractures with proper surgical technique and arthroplasty

or our-part ractures,16 other investigators now argue that,

despite the higher incidence o avascular necrosis in our-part

ractures as compared to three-parts,19-21 the decision to treat

with operative fxation versus arthroplasty should ideally be

based on multiple actors (including patient age and activity

level, treatment goals, and medical co-morbidities).

Currently, reported rates or avascular necrosis vary rom

3% to 37%.17 In that regard, to minimize these rates, an ac-

curate assessment o humeral head vascularity is crucial in

determining both the viability and the prognosis ollowing

a proximal humerus racture. The Hertel criteria employs

radiographic markers to determine the adequacy and qual-

ity o humeral head vascularity by examining the extent o

metaphyseal extension o the proximal humerus racture and

the amount o medial hinge disruption.22 The investigators

ound that the integrity o the medial hinge and the length

o the posteromedial metaphyseal head extension were key

predictors o vascular disruptions. Specifcally, metaphyseal

head extension less than 8 mm and medial hinge disruption

greater than 2 mm were good predictors o humeral head

ischemia. Recently, Crosby, using tetracycline labeling or

displaced three- and our-part ractures, demonstrated a high

rate o vascular preservation, especially in younger patientsin the anterosuperior aspect o the humeral head.17 In ad-

dition to examining the racture pattern as recommended

by Hertel, an adequate understanding o the humeral head

vascular anatomy, surgeon expertise, the patient’s physi-

ologic status, activity level, and expected outcome should

all be collectively considered to maximize patient outcomes

and minimize humeral head necrosis.17

Operative Modalities

The gradual shit to operative treatment o these complex

ractures was spurred by both an improvement in implant

technologies and techniques, along with concurrent increases

in patient and surgeon expectations or improved unctionaloutcomes. The introductions o locking plates and reverse

shoulder arthroplasties (RSA) have expanded the options

available or treatment, while concurrently generating ur-

ther controversy.

Closed Reduction and Percutaneous Pinning The advantage o closed reduction and percutaneous fxa-

tion is that it can be perormed with minimal surgical dis-

section and can potentially decreased risk o humeral head




vascular supply disruption. Resch reported percutaneous

fxation o three- and our-part ractures in 27 patients and

ound that at an average o 24-months ollow-up all three-

part ractures demonstrated good to very good unctional

results without avascular necrosis.23 Good radiographic

results were achieved in the our-part ractures but only when

they initially presented in a valgus-impacted manner. Theinvestigators concluded that the medial periosteum serves as

both an important source o vascular supply and as a hinge

or reduction maneuvers (Fig. 1).

This is a technically demanding procedure, especially or

more complex proximal humerus ractures. It is a reasonable

alternative or AO type A ractures with greater than 66%

translation and combined cortical thickness greater than 4

mm, but may not be as good an option in osteoporotic bone

and comminuted ractures since this technique requires

adequate cortical purchase.

Intramedullary Nail Fixation

The use o antegrade intramedullary nail fxation or dis-placed proximal humerus has been reported as an alternative

method o treatment to perorm stable fxation with minimal

sot tissue dissection. Some investigators have also argued

that in addition to the preservation o the periosteal blood

supply, intramedullary techniques limit operative time,

surgical exposure, and length o hospital stay.24

Most studies that have been published on these implants

have investigated their use in displaced proximal humerus

ractures with an intact head ragment.25-28 In a prospective

study by Stedteld,29 112 consecutive patients with displaced

ractures were treated and evaluated. The investigators ound

good unctional results in two- and three-part ractures.

However, the investigators had a 16% complication rate.

They reported that, in our-part ractures, a substantial risk

o post-operative complications and bad unctional results

exist. Koike evaluated 54 patients with two-, three-, andour-part ractures treated with intramedullary nailing30 and

ound that none o the patients developed avascular necrosis.

Seventy-nine percent o patients reported satisactory to ex-

cellent results. However, only three o their treated patients

had our-part ractures.

Adedapo and Ikpeme evaluated the role o intramedul-

lary nail fxation in three- and our-part ractures. 31 At the

one-year ollow-up, the median Neer scores were 89 and 60

or the three- and our-part ractures, respectively. However,

13% o their patients, all o whom were in the our-part

group, continued to have signifcant pain at fnal review.

Complications noted in their series included proximal screw

loosening and extrusion in three patients and avascular ne-crosis in one patient. The use o intramedullary implants is

not ideal or our-part or osteoporotic ractures.

Open Reduction Internal Fixation with Locking

Plate With the advent o locked plates, this technology was ap-

plied to the proximal humerus to provide the advantages o

a fxed-angled implant without the difculties and limita-

tions o frst generation fxed angle (blade plate) fxation.

Figure 1 A, Displaced two-part proximal humerus racture in a skeletally immature patient, B, treated with closed reduction and per-cutaneous pinning. C, Six months post-operatively, ater the pins were removed.

C

B

A




Currently, most o these implants are precontoured to the

anatomy o the lateral proximal humeral metaphysis and

unction as an internal fxator providing angular stability

(Fig. 2).24 Advantages o these implants include the ability to

obtain anatomic reduction with less racture devitalization,

preservation o the rotator cu integrity, ability to maintain

stable fxation in the ace o signifcant comminution and

osteoporosis, and multi-angle screw fxation.24,32

In a bio-mechanical cadaveric study perormed by Siri, simulated

humerus neck ractures subjected to cyclic loading compar-

ing locking plate constructions to blade plates demonstrated

signifcantly greater torsional stiness o locking plates

and similar bending stability between the two.33 Weinstein

and coworkers34,35 ound similar results, and Edwards and

colleagues35 noted that a locking plate was ar superior to a

proximal humerus nail in both varus bending and torsional

stability. Given that most proximal humerus ractures ail

secondary to rotational and bending moments, such added

stability potentially prevents many o the ailures noted with

other implant types.36,37

Despite these promising biomechanical results, earlyclinical studies evaluating the results o proximal humerus

locking plates were mixed. Kettler reported on 225 rac-

tures treated with the PHILOS (Synthes, Stratec Medical

Ltd, Mezzovico, Switzerland) proximal humerus locking

plate.38 In their series, the investigators reported a high rate

o complications resulting rom technical error, includ-

ing malreduction (14%), screw perorations (11%), and

implant dislocations (4.5%). Similarly, Bjorkenheim39 and

Fankhauser40 reported hardware ailure, nonunion, avascular

necrosis, and malunion as complications in their series using

the PHILOS plate.

Later studies utilizing the plate demonstrated more

promising results. Moonot evaluated the PHILOS plate in 32

patients with displaced three- and our-part ractures, with

an average age o 59.9 years.41 Distinct rom previous stud-

ies, the investigators addressed bone deects with bone grat

substitutes, while tuberosity displacement was treated withanatomic reduction. As a result, the mean Constant score

was 66.5, without signifcant dierences in outcomes when

comparing patients below and above 60 years o age. They

demonstrated a 6% malunion rate and a 3% rate o nonunion

and avascular necrosis. Similar fndings were also ound by

Papadopoulos.42 Shahid,43 however, ound that those who

were elderly or had racture-dislocations perormed slightly

poorer with this fxation.

Other studies44-45 examining the use o locking-plate con-

structs in three- and our-part ractures demonstrated compa-

rable results. Hente44 noted a 16% rate o avascular necrosis;

however, their study did include racture-dislocations (which

were responsible or 80% o these complications). Compli-cations in their series were related to hardware, including

greater tuberosity displacement and screw loosening. Hente

strongly recommended this construct with tension band wir-

ing o the tuberosities as an alternative to prosthetic replace-

ment. Hirschmann46 ound, at one year postoperatively, that

the range o motion o the injured side was 80% that o the

contralateral side. Moreover, absolute and relative Constant

scores signifcantly improved rom six-months (average 56)

to twelve-months (average 65) postoperatively. One over-

Figure 2 A, Displaced three-part proximal humerus racture-dislocation in a 42-year-old patient, B, treated with open reduction internalfxation with a proximal humerus locking plate.

BA




riding concept that can be garnered rom these studies is the

importance o intra-operative reductions, particularly o the

tuberosities on unctional outcomes.44-45

Solberg retrospectively examined 70 patients older than

55 years o age with three- or our-part proximal humerus

ractures treated with locked plates.47 His study indentifed

two groups based on the initial direction o the humeral head

deormity: those with varus deormity and those with valgusdeormity. Complications o avascular necrosis, humeral

head peroration, loss o fxation, tuberosity displacement,

and varus subsidence were encountered in 79% o those with

varus deormity as compared to 19% o those with valgus

deormity. Constant scores or all three-part ractures were

also signifcantly better than our-part ractures, but dier-

ences between the varus and valgus subgroups were only

signifcant or the three-part group (p < 0.01, as compared to

p = 0.19 or the our-part subgroups). The investigators elt

that, because the locking plate unctions as a tension band

by “pulling” the humeral head out o varus, the initial varus

malalignment placed the implant at a distinct mechanical

disadvantage (especially in osteoporotic bone). Solberg

also ound that ractures with metaphyseal segment length

o less than 2 mm had a higher risk o developing avascular

necrosis. The investigators concluded that the angulation

o the initial deormity and the length o the metaphyseal

segment attached to the articular ragment have a signifcant

inuence on fnal outcomes in these ractures.

Agudelo and coworkers examined the predictors o loss

o fxation in proximal humerus locking plate fxation.48 In

their series, the overall incidence o loss o fxation was

13.7%. They ound that there was a statistically signifcant

association between varus malreduction and loss o fxation

(30.4% when the head-shat angle was below 120° versus11% when the head-shat angle was greater than 120° [p =

0.02]). Similarly, Lee attempted to determine the prognostic

actors or successul clinical outcomes.49 They concluded

that delay in rehabilitation and decreased head-neck shat

angle, caused by lack o medial support, were the primary

actors that led to poor outcome. Other investigators, such

as Micic50 and Clavert,51 also ound that early post-operative

ailures o the locking plate were associated with initial mal-

reduction, poor operative technique (including inadequate

screw length or plate positioning), loss o medial support,

and ailure to adequately fx the tuberosities.

Prosthetic Replacement The use o primary arthroplasty in displaced three- and

our-part proximal humerus ractures was frst proposed by

Neer.16 Non-locking internal fxation gave mixed results, and

concerns regarding avascular necrosis compelled many sur-

geons to treat complex ractures primarily with arthroplasty

options.16,24,52-54 With improved fxation implants available,

arthroplasty has become reserved or treating ractures that

are more technically demanding to reconstruct (i.e., our-part

ractures with complex racture patterns and signifcant ar-

ticular involvement, especially in patients older than 60 years

o age and head splitting ractures). However, unctional

results are only moderately satisactory, despite predictable

pain relie.55 With the increasing popularity o reverse shoul-

der arthroplasties (RSA), the role o arthroplasty has been

revisited. Regardless o which primary arthroplasty option

is selected, aseptic loosening, periprosthetic ractures, inec-

tions, and dislocations can occur and must be considered.24

Hemiarthroplasty The indications or hemiarthroplasty in the management o

proximal humerus ractures, although evolving due to the

advent o locking-plate implants, have traditionally been

or our-part ractures, three-part ractures in older patients

with poor bone quality, racture-dislocations, head-splitting

ractures, and ractures involving greater than 40% o the

articular surace.56-58 Concerns regarding the higher rates

o avascular necrosis in our-part ractures and the tenuous

fxation o racture ragments in osteoporotic bone have led

most surgeons to advocate hemiarthroplasty as the preerred

option over internal fxation (Fig. 3).56 Valgus-impacted

our-part ractures demonstrate a signifcantly lower rate o

avascular necrosis and thus are an exception to this preer-

ence or hemiarthroplasty.3,59

Recent studies have demonstrated that, despite predict-

able pain relie, hemiarthroplasty provides inconsistent

unctional outcomes.55,60,61 These fndings are in contrast to

earlier studies that demonstrated more reliable unctional

results.56,57,62,63 It has been shown that early passive range o

motion post-operatively, ollowed by long-term active range

o motion and strengthening, is essential to achieve optimal

outcomes ater shoulder hemiarthroplasty.62,64,65 However,

the insufcient bony healing o displaced tuberosities a-ter intra-operative fxation at the stem o the prosthesis,

malpositioning o the tuberosity ragments, and incorrect

positioning o the prosthesis are probably the most important

actors determining the outcomes o this treatment modal-

ity.24,36,64,66,67

Approximately 4% to 50% o shoulders treated with

hemiarthroplasty experience malunion or nonunion o tuber-

osity fxation, resulting in the most signifcant complication

ater hemiarthroplasty or proximal humerus ractures.58,65,68

A recent multicenter study by Kralinger and associates re-

vealed that tuberosity positioning is a signifcant actor in

the unctional outcome o hemiarthroplasties or ractures

o the proximal humerus; however, pain did not correlatewith displacement o the tubesrosity.62 These fndings were

also reported by Mighell57 and Coleman69 in their reviews.

Aside rom devascularization and inadequate fxation that

may lead to tuberosity nonunion, Boileau determined that the

actors most commonly associated with tuberosity malunion

include poor intra-operative positioning o the prosthesis,

age, sex, and initial malposition o the greater tubosity.68

Due to importance o anatomic restoration o humeral

head position, studies have assessed the use o intra-operative




anatomic landmarks, such as the bicipital groove, to deter-

mine the appropriate 30° to 40° o retroversion or prosthesis

orientation.67 Christoorakis and colleagues proposed using

the contralateral humerus to estimate the proper retroversion

or each patient as an individualized approach to restoring

native anatomy.64 However, a recent study by the same inves-

tigator has ound that, when evaluating the mean Constant

scores using these two techniques, there is no dierence.64

However, the results o this study are limited secondary to

its small sample size.

Use o bony landmarks when assessing or proper pros-

thesis orientation is limited by the distortion that occurs in

complex ractures. Murachovsky validated the use o the

pectoralis major tendon as a reproducible landmark or ac-curate restoration o humeral height with hemiarthroplasty

reconstruction.70 By dissecting 40 cadaveric shoulders, he

determined that the distance between the upper border o

the pectoralis major tendon insertion on the humerus and

the top o the humeral head averaged 5.6 cm ± 0.5 cm. This

provides an easily reproducible intraoperative check o

prosthetic humeral head height.

The third actor inuencing outcome with arthroplasty

is the union o the tuberosities. A cadaveric study by de

Wilde examining the strength o fxation o the bone-ten-

don interace o the rotator cu to the articular rim o the

hemiarthroplasty prosthesis ound that it is strong enough

to resist racture ragment displacement under orces as-sociated with activities o daily living.71 Frankle and col-

leagues determined that circumerential cerclage around the

tuberosities decreases interragmentary motion and strain,

maximizes racture stability, and acilitates post-operative

rehabilitation.72 However, Pijls and associates presented a

new sling technique or tuberosity fxation in uncemented

hemiarthroplasty or severe ractures o the proximal hu-

merus, due to concerns regarding suture damage rom the

edges o the drill holes in traditional tuberosity fxation

techniques.73 The investigators elt that in some cases the

sutures placed by standard drill holes ailed due to suture

cut-out through osteoporotic bone, leading to suboptimal

tuberosity positioning. The investigators ound that their

sling technique provided better tuberosity positioning, stable

fxation (which they elt translated to improved unctional

outcomes), patient satisaction, and pain scores as compared

to traditional drill-hole techniques.

Heterotopic ossifcation, glenoid degeneration, prosthetic

loosening, and axillary nerve injury may also be seen with

hemiarthroplasty treatment. Reported rates o heterotopic

ossifcation range rom nine to 56%.57,65,68 While the studies

do not specifcally indicate a reason or this dierence, it has

been shown that patients with hemarthrosis or concomitantrotator cu tears have a signifcantly higher risk o hetero-

topic ossifcaiton.24,74,75 Mighell and coworkers57 have also

reported an 8% rate o glenoid degeneration at an average

o three-year ollow-up, while Parsons and associates76 have

determined that unctional outcome, as determined by the

Constant score, is negatively correlated with joint space

narrowing and glenoid degeneration.77 Other complications,

such as prosthetic loosening, inection, and nerve injury are

rarer, occurring at reported rates o 3% to 6%,64,65 1% to

2%,57,63 and less than less than 1%,57,63-65 respectively.77

The optimal timing o hemiarthroplasty treatment has also

been evaluated. Acute reconstruction is technically easier

and has been shown to be preerable to delayed hemiarthro-plasty. Mighell57 ound statistically signifcant improvement

in ASES scores in patients treated within 2 weeks o initial

injury, and Becker78 determined that ractures treated early

with hemiarthroplasty showed better shoulder motion by

video motion analysis and clinical outcomes when treated

within 2 weeks o injury. In contrast, Prakash and cowork-

ers65 did not fnd any dierence in his series o early (less

than 30 days) versus late (greater than 30 days, average

time rom injury to surgery was 13 months) treatment with

Figure 3 A, Displaced our-part proximal humerus racture-dislocation in a 62-year-old patient, B, treated with hemiarthroplasty.

BA




hemiarthroplasty with regards to range o motion.77 While

the optimal timing on hemiarthroplasty replacement remains

controversial, it can be inerred rom these studies that earlier

surgery tends to lead to better outcomes.

Reverse Total Shoulder Arthroplasty Concerns related to the positioning and healing o the tuber-

osity in hemiarthroplasty have led to the development anduse o reverse shoulder arthroplasty (RSA) or the treatment

o proximal humerus ractures, particularly in the elderly.

By converting the glenoid into a spherical head and the

head o the humerus into a socket, the center o rotation o

the glenohumeral joint is medialized, giving the deltoid a

more eective moment arm (Fig. 4).79 This new relationship

eliminates the detrimental eect generated rom rotator cu

defciency resulting rom tuberosity malunion or nonunion.

Boileau80 and Cazeneuve evaluated the Grammont reverse

shoulder prosthesis in traumatic cases and, although evaluat-

ing only a small series and reporting on early results, ound

this method to be acceptable.

Buquin and colleagues evaluated the reverse total shoul-

der arthroplasty in 43 consecutive patients with a mean age o

78 years in a prospective review with short-term ollow-up.79

Patients with three- or our-part ractures o the proximal

humerus were treated with a RSA. Patients were ound to

have satisactory clinical outcomes, with a mean anterior

elevation o 97° and a mean active external rotation in abduc-

tion o 30°. The mean Constant scores, however, were only

44. Complications included reex sympathetic dystrophy,

neurologic injury (most o which resolved), and anterior

dislocation. Despite these fndings, the investigators pro-

posed that RSA is an attractive alternative that still requires

long-term investigation. A recent study by Cazeneuve andCristoari evaluating radiographic outcomes at an average

ollow-up o 6.5 years demonstrated that, or acute proximal

humeral ractures in the elderly, unsatisactory radiographic

images were obtained in 70% o cases.81 These unsatisac-

tory changes included evidence o glenoid loosening and

scapular notching. However, only one revision was required

at 12-year ollow-up.

Levy and colleagues examined the use o RSA as a treat-

ment or ailed hemiarthroplasty or proximal humerus rac-

tures.82 Over a fve year period, 29 patients with a mean age

o 69 previously treated with hemiarthroplasty were revised

to a RSA (or glenoid arthritis or rotator cu defciency rom

tuberosity malpositioning). Proximal humeral allograts

were used in cases where signifcant bone deects were en-countered. Ater ollow-up or an average o 35 months, the

average total ASES score improved rom 22.3 preoperatively

to 52.1 (p < 0.001). There were also signifcant improve-

ments noted in the ASES pain score, orward exion, and

abduction. There was a trend towards improvement in the

ASES unctional score, but it was not statistically signif-

cant. The overall complication rate, however, was 28%. The

investigators concluded that the RSA oers a salvage-type

solution to the problem o ailed hemiarthroplasty due to

glenoid arthritis, tuberosity and rotator cu defciency, and

implant ailure.

Currently, the role o RSA in primary and late salvage

treatment o proximal humerus ractures is still being inves-

tigated. However, early evidence does show that it may have

a role in primary treatment when tuberosity reconstruction is

not a viable option or when salvage rom a previously ailed

hemiarthroplasty is required.

Conclusion

Although no level one data exists, the literature suggests

that three-part ractures are better treated with internal

fxation with locking plates,83 especially those presenting

with initial valgus displacement and those that possess a

longer medial metaphyseal segment.47 Recommendations

or most displaced three-part ractures include internalfxation, with the option o prosthetic replacement or those

not amenable to humeral head preservation techniques.3,18

I surgical treatment is chosen, select our-part ractures in

the elderly may be better treated with arthroplasty, with the

exception o the valgus impacted our-part ractures.3,23,59

One must understand that the ability to re-establish adequate

Figure 4 A, Displaced our-part proximal humerus racture in an 84-year-old patient, B, treated with reverse shoulder arthroplasty.

BA




head-neck shat angulation, anatomic reduction o the tu-

berosities, and obtain adequate post-operative rehabilitation

are vital to success and help determine optimal outcome

i this option is chosen.47-49,84 The role o reverse shoulder

arthroplasty is currently being investigated, but may prove

to be another tool in the armamentarium in the treatment o

these complex injuries.

Regardless o implant technology, sound technique, accu-rate anatomic reduction, and proper patient selection are the

most important actors in determining treatment success.84

Thereore, the surgeon is not advised to use one treatment

option or all types o displaced proximal humerus ractures.

The various methods available at the surgeon’s disposal

serves as a spectrum o treatment options that, when used

appropriately, can maximize the outcomes o this difcult

clinical challenge.

Disclosure Statements Drs. Min and Davidovitch have nothing to disclose. Dr.

Tejwani or a member o his immediate amily is a member o

a speakers’ bureau or has made paid presentations on behal

o Stryker, Biomet, and Zimmer and has received research

or institutional support rom Biomet. Dr. Tejwani is also a

product developer or the Biomet OptiLock Upper Extremity

Plating System Proximal Humeral Plates.

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