Proximal Humerus 3
be increased (intuitive) by operating on it.

If AVN were to occur, how significant would that be?

– symptoms and radiographic evidence may be delayed up to 2 years or more!

Þ Gerber, C., Hersche O., Berberat C., The clinical relevance of post-traumatic avascular necrosis of the humeral head., Journal of Shoulder and Elbow Surgery, 7(6): 586-590, Nov-Dec 1998.

· 25 patients with AVN at an average of 7.5 years.

· Group 1 – 13 with anatomic or near anatomic healing of fracture
– functional result comparable to hemiarthroplasty

· Group 2 – 12 with malunion of 1 or more of the fragments
– significantly worse functional (Constant) score than Group 1

Þ Hattrup S.J., Cofield R.H., Osteonecrosis of the humeral head: relationship of disease stage, extent, and cause to natural history, Journal of Shoulder and Elbow Surgery, 8(6): 559-564, Nov-Dec 1999.

· 151 patients with 200 affected shoulders (corticosteroids in 112, trauma in 37, Gaucher’s in 3, sickle cell in 3, radiation in 1, idiopathic in 44).
· 97 shoulders had replacement surgery.
· post-traumatic shoulders required surgery more often – cumulative rate of 77.8% by 3 years.

Clearly, AVN can occur regardless of the treatment (ie – a function of the actual injury). The incidence is increased by performing an open reduction. A wide spectrum of head involvement and severity of collapse exists, with a corresponding spectrum of clinical symptomatology. It would appear that the surgeon can affect some influence on the spectrum of symptomatology by successfully restoring the anatomy. Ie – if one is to undertake internal fixation, it should be acknowledged that the risk of AVN will increase (particularly with an extensive dissection), but that if it were to happen, the clinical significance of it may be reduced by successfully restoring the anatomy.

What are the results of acute hemiarthroplasty?

Þ Neer C.S., Displaced Proximal Humeral Fractures: II. Treatment of Three-Part and Four-Part Displacements. Journal of Bone and Joint Surgery, 52A: 1090-1103. 1970

· 117 patients – 61 three-part, 56 four-part
· Followed for 1 to 16 years, average 4.8. 37 followed from 1-2 years, 46 from 2-5 years, 14 from 5-10 years, and 20 from 10-16 years.
· 31 treated with closed reduction
· 43 treated with open reduction
· 43 treated with hemiarthroplasty.
· 100 point scale described in his previous article, based on pain (35 points), function (30 points), range of motion (25 points), and alignment (10 points). Excellent – above 89, satisfactory, above 80, unsatisfactory, above 70, failure, below 70.

11 three-part fractures treated with hemiarthroplasty: 1 excellent
7 satisfactory
1 unsatisfactory
2 failures.

32 four-part fractures treated with hemiarthroplasty: 4 excellent
27 satisfactory
1 failure.

In total, 43 patients with acute hemiarthroplasty, 39 excellent-satisfactory outcomes.

– no one, in North America or Europe,
has since been able to reproduce this success.

Others’ experiences with hemiarthroplasty:

Þ Movin T., Sjoden G.O., Ahrengart L., Poor function after shoulder replacement in fracture patients. A retrospective evaluation of 29 patients followed for 2-12 years. Acta Orthopaedica Scandinavica, 69(4), 392-4, August 1998.

· 29 proximal humerus fractures, average age 71; 18 treated acutely, 11 treated late
· overall poor Constant score means (38)
· substantial rest and activity related pain
· no difference between acute and late.

Þ Zyto K., Wallace W.A., Frostick S.P., Preston B.J., Outcome after hemiarthroplasty for 3 and 4-part fractures of the proximal humerus. Journal of Shoulder and Elbow, 7(2): 85-89, Mar-April 1998.

· 17 three-part, 10 four-part fractures followed for 39 months (average)
· Constant score: 51 for 3-part, 46 for 4-part
· ROM median: flexion 70, abduction 70, IR 50, ER 40
· 9 of 27 with severe or moderate pain
· 8 of 27 with severe or moderate disability

“It is disappointing that the results with respect to

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