Arthroplasty and acute shoulder trauma. Reasons for success and failure.

Successful treatment of acute fractures of the proximal humerus with prosthetic replacement is a therapeutic challenge to the orthopaedic surgeon, and requires proper elevation of the patient, proper surgical technique, and meticulous rehabilitation. Fractures that require prosthetic replacement as the definitive treatment include 4-part fractures and fracture dislocations, head-split fractures with > 40% articular surface involvement, and selected 3-part fractures. The trauma series of radiographs (including true anteroposterior and lateral views in the scapular plane, and axillary view) is essential for accurate fracture evaluation. Factors important for a successful outcome include gentle soft tissue technique, secure placement of the prosthesis with proper version and height, secure tuberosity reconstruction, meticulous rotator cuff repair, and a motivated patient who is able to understand and perform the rigorous postoperative rehabilitation. Postoperative rehabilitation must be individualized in each case, and the treatment plans should be carefully outlined by the operating surgeon at the completion of the surgical reconstruction. Of 70 cases treated with prosthetic replacement, results were excellent in 31, satisfactory in 22, and unsatisfactory in 17. Unsatisfactory results were associated with tuberosity detachment, prosthetic loosening, inadequate or noncompliant rehabilitation, preoperative nerve injury, humeral malposition, dislocation, deep infection, and ectopic bone formation.

Operative treatment of nonunions of the surgical neck of the humerus.

Twenty patients underwent surgical reconstruction for nonunion of fractures of the surgical neck of the humerus. Average time from injury to surgery was 10 months (range 4 to 14 months). The operation consisted of bone grafting combined with humeral head replacement in 10 cases and open reduction and internal fixation in 10 cases. Results, at an average follow-up of 51 months (range 24 to 124 months), were excellent in five (25%), satisfactory in six (30%), and unsatisfactory in nine (45%). Twelve nonunions resulted from fractures initially treated with close reduction; repair of these nonunions achieved by 67% excellent or satisfactory results. Eight nonunions resulted from fractures initially treated with internal fixation; repair of these nonunions achieved only 38% excellent or satisfactory results. Fifteen complications, 11 of which necessitated reoperation, occurred. Surgical reconstruction for nonunions of the surgical neck of the humerus usually results in significant improvement in pain but much more modest improvement in active motion and function. Surgery should be reserved for patients with significant symptoms and disability.