Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus

The purpose of this multicenter study was to analyze the results of shoulde r arthroplasty for the treatment of the sequence of proximal humerus fractu res and establish an updated classification system and treatment guidelines for these complex situations. Seventy-one sequelae of proximal humerus fra ctures were treated with shoulder replacement with the use of the some nonc onstrained, modular, and adoptable prosthesis: the Aequalis prosthesis (Tor nier Inc, St Ismier, France). The average time between initial fracture and shoulder arthroplasty was 5 years and 5 months. On the basis of anatomic c lassification schemes, sequelae were divided into 4 types: type 1, humeral head collapse or necrosis with minimal tuberosity malunion (40 cases); type 2, lacked dislocations or fracture-dislocations (9 cases); type 3, nonunio ns of the surgical neck (6 cases); and type 4, severe malunions of the tube rosities (76 cases). The mean postoperative follow-up was 79 months (range, 12 to 48 months). Overall, the postoperative Constant score was excellent in 11 cases (16%), good in 19 cases (16%.), fair in 18 cases (25%), and poo r in 23 cases (33%). There were 18 complications (27%). Fifty-nine of 70 pa tients (81%) stated that they were satisfied with the result. The most sign ificant factor affecting functional outcome was greater tuberosity osteotom y (P < .005). Regarding both surgical treatment and postoperative prognosis , we identify 2 categories of proximal humerus fracture sequelae: category 1, intracapsular/impacted fractures sequelae (associated with both cephalic collapse or necrosis [type 1] and chronic dislocation or fracture-dislocat ion [type 2]), in which an articulating joint can be reconstructed without a greater tuberosity osteotomy; and category 2, extrocapsular/disimpacted f ractures sequelae (associated with both surgical neck nonunions [Pipe 3] an d severe tuberosity malunions [type 4]) where the proximal humerus cannot b e reconstructed without a greater tuberosity osteotomy All of the excellent and good postoperative Constant scores were obtained in type 1 and 2, in w hich osteotomy of the greater tuberosity was not required. All patients in type 3 and 4, who underwent a greater tuberosity osteotomy, had either fair or poor results and did not regain active elevation above 90 degrees. We c onclude that a greater tuberosity osteotomy is the most likely reason for p oor and unpredictable results after shoulder replacement arthroplasty for t he treatment of the complex sequelae of proximal humerus fractures. Shoulde r arthroplasty for the treatment of the sequelae of fractures of the proxim al humerus should be performed without an osteotomy of the greater tuberosi ty when possible. if prosthetic replacement is possible without an osteotom y, surgeons should accept the distorted anatomy of the proximal humerus and adopt the prosthesis and their technique to the modified anatomy. A modula r and adaptable prosthesis with both adjustable offsets and inclination may allow surgeons to adopt to a large number of malunions and may help to avo id the troublesome greater tuberosity osteotomy in a higher proportion of c ases.