In elderly patients with a proximal humeral fracture that carries specific high-risk morphological features, open reduction and internal fixation may fail to achieve the radiographic and anatomical goals required for a durable result. This protocol addresses the next surgical step in that situation.
Age 65 years or older, with a proximal humeral fracture characterised by one or more of the following:
The majority of these injuries are fragility fractures in low-demand elderly patients. Osteoporotic bone quality makes stable fixation particularly challenging and is associated with high surgical failure rates.
This protocol follows cases where open reduction and internal fixation with locking plates and screws — together with bone grafting of the humeral head, medial pillar support, and greater tuberosity repair — was performed but did not achieve one or more of the following:
Non-union of tuberosities and varus collapse with screw cut-out are recognised failure modes in fragile osteoporotic bone. When these outcomes are not achieved, a different surgical approach is indicated.
The majority (>80%) of these are fragility fractures, occurring in low demand (often elderly) patients. Weak osteoporotic bones not only break easily but are also difficult to stabilize and are often associated with high failure rates, after the surgery.
Dislocated head. Head facing superiorly/posteriorly (though in the socket, but not facing the glenoid). Splitting of head. GT is lying above the humeral head or displaced posteriorly. Significant varus angulation of the head (usually indicates severe medial pillar instability & progressive malposition).
In elderly patients, HA (with fracture prosthesis) can be used. However, failure rates are high because of the nonunion of tuberosities. Non-union of tuberosities and varus collapse leading to screw cut-outs are common in fragile bones. RSA offers an attractive alternative approach.
DOI: 10.1016/j.jcot.2019.04.016
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