Proximal Humerus 5
These findings should be considered when treatment is selected for acute 3 and 4-part proximal humerus fractures.”

Þ Bosch U. Et al., Outcome after primary and secondary hemiarthroplasty in elderly patients with fractures of the proximal humerus, Journal of Shoulder and Elbow Surgery, 7(5): 479-484, Sept-Oct 1998.

· 11 patients treated within 4 weeks, 15 patients treated after 4 weeks
· active forward elevation was better in the early group.
· no difference on their HSS scores, and by their self-assessment.
· poor results in 20% UCLA, 28% Constant, 56% HSS!
· concluded that the outcome after early hemiarthroplasty was better than after late replacement, as based on the UCLA and Constant scores.

“The decision to perform prosthetic humeral head replacement in elderly patients should be made as early as possible after trauma.”

Þ Muldoon M.P., Cofield R.H., Complications of Humeral Head Replacement for Proximal Humeral Fractures, Instructional Course Lectures, Volume 46, 1997.

· Reviewed 5 series of delayed treatment for chronic fracture-related problems
· 100 patients, 41 complications
· infection 3, nerve injury 2, intraoperative fracture 2, instability 10, tuberosity nonunion 7, rotator cuff tear 7, HO 8.

Mayo clinic experience:
· 55 patients, followed for average 57 months
· problems leading to surgery: nonunion 17, AVN 9, arthritis 9, malunion 8, bad primary hemiarthroplasty 8, dislocation 2, flail shoulder 1, HO 1.
· 14 with more than mild residual pain
· average active elevation 97o
· patients with failed humeral head replacements did worse than failed ORIF
· complications: infection 3, fracture 3, instability 10, tuberosity nonunion 2, rotator cuff tear 4, implant malposition 3, glenoid arthritis 7, implant loosening 2.

It would appear that delayed treatment is worse than acute hemiarthroplasty, but one’s philosophy on this partially depends on how good you believe the results of acute hemiarthroplasty really are. There is some evidence to suggest that revision of an acute hemiarthroplasty is even worse than doing a delayed hemiarthroplasty for a failed ORIF. Tuberosity detachment has significant importance in the prognosis of the hemiarthroplasty, and should be carefully regarded.

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