Hemi-arthroplasty--primary or secondary measure for 3- and 4-fragment fractures of the proximal humerus in the elderly?

Successful treatment of three- and four-part proximal humerus fractures is a therapeutic challenge to the surgeon, particularly in the case of elderly patients. Open reduction and internal fixation have been advocated, but have not consistently produced acceptable results. The results of humeral head replacement as a salvage procedure after non-union or failed open reduction and internal fixation are less predictable. The outcome of hemiarthroplasty (Neer II) performed for three- and four-part proximal humerus fractures in elderly patients was studied. The average patient follow-up was 42.9 months (range 5-98). Eighteen women and eight men with an average age of 64.5 years were evaluated according to the UCLA. Constant-Murley and HSS Score. A Visual Score (0-100 points) was also used. Hemiarthroplasty was performed in 11 patients within 4 weeks of trauma and in 15 patients after 4 weeks. Fair, good, or excellent results were achieved in 80% (UCLA and Visual), 73% (HSS) and 46% (Constant-Murley) of the patients, respectively. Ninety-six percent of the patients reported only slight or no pain. The range of motion was limited in almost all cases. The outcome was not significantly influenced by age, sex and follow-up time. However, there was a significant correlation between the outcome and the length of time between injury and humeral head replacement (r = -0.5). The outcome after early hemiarthroplasty was better than after late humeral head replacement (UCLA: 27.1 +/- 4.6 vs 22.5 +/- 5.6 P = 0.04; Constant-Murley: 65.6 +/- 18.5 vs 47.5 +/- 18.6, P = 0.02; HSS: 74.0 +/- 14.4 vs 63.5 +/- 17.6, P = 0.17). Self-assessment did not differ between these two groups. After early hemiarthroplasty, active forward flexion was significantly better. This study indicates that early humeral head replacement for three- and four-part proximal humerus fractures in elderly patients achieved better functional outcome than delayed humeral head replacement. The decision to perform prosthetic humeral head replacement in these cases should be made as early as possible after trauma.