Surgical management of proximal humeral fractures (PHF) remains problematic with a high failure and reoperation rates. Some studies compared the functional results of ORIF and arthroplasty for the surgical management of 3- and 4- part fractures. The results found were mixed. Other studies have concluded to the presence of several factors that can predict the failure of osteosynthesis and cause a poor outcome [9].
Recognizing patient and fracture characteristics is crucial in choosing the best treatment. The vascularization status of the humeral head must be evaluated.
Age in an important factor when choosing the adequate treatment. Yahuaca et al [10] reported that the majority of patients aged > 65 years old were treated with RSA while the other patients were more likely to undergo a conservative surgical treatment. These findings were consistent with Gupta’s et al [11] in their systemic review of studies comparing ORIF, hemiarthroplasty and RSA for fractures of proximal humerus. Many studies reported worse outcomes with ORIF in this population. Hardeman et al [9] reported worse functional outcomes and higher re-operation rates when treating old patient with ORIF. Yahuaca et al [10] found the same results with increased non-union and reoperation rates in patients > 65 years old. They attributed these findings to poorer bone quality in this population.
Some studies [12] evaluated the relationship between a higher ASA [13] score and the failure rate. They found that patients with higher ASA score were likely to undergo arthroplasty, and were associated with more surgical complications and prosthetic failure.
The second factor with a significant difference in the type of surgical management is Neer’s fracture classification. Two-part PHF were more likely to be treated conservatively, while patients with 4-part fractures were more likely to undergo RSA. However, the optimal treatment of 3-part fractures remains difficult to determine with authors preferring RSA and others defending ORIF. The treatment is based on multiple factors like bone quality but mostly on the perfusion of the humeral head. Hertel et al [14] examined risk factors of humeral head ischemia. Predictors of ischemia were: short metaphyseal head extension (< 8 mm), the disturbance of the medial hinge (displacement > 2 mm) and the fracture pattern. Kloub et al [15] showed that the quality of the reduction is an important factor of determining the risk of humeral head necrosis (HHN). HHN was observed in only 2% of fractures with good reductions, but in 60% of fractures with bad reductions.
Bastian et al [16] reported that initial ischemia after intracapsular fracture did not necessarily lead to the developpement of osteonecrosis. Vice versa, avascular necrosis may occur unexpectedly in initially perfused heads.
Avascular necrosis leads to worse functional outcomes. As soon as humeral head collapse causing screw perforation, functional scores dropped dramatically and patients suffered from pain [17].
The pattern of the fracture is also an important factor. Many series have reported poor functional outcomes of varus-impacted fractures [18]. Hardeman et al [9] reported a higher failure rate with these fractures, whereas valgus-impacted fractures result in a relatively low rate of osteonecrosis because residual vascularity may be maintained through an intact medial soft-tissue sleeve [19]. Varus-impacted fractures are more likely to disrupt this sleeve and more likely to be instable.
Reoperation rate is an important factor when deciding the appropriate management for PHF. Gupta et al [11] reported a higher reoperation rate of 12.7% in ORIF vs 5% in RSA. Yahuaca et al [10] noted the same results with 17.1% in ORIF vs 6.6% in RSA.
The elderly patients are a fragile population with a high level of postoperative morbidity and mortality rates. This needs to be considered when making the treatment decision.
Many authors have analyzed predictive factors of failure in ORIF in order to assist the surgeon in the decision-making process in managing these difficult fractures. A significantly displaced, poorly vascularized varus articular fracture in the older patient predicts a poor outcome [9]. Thus, we think this is the ideal indication of RSA.
Our study has its limitations. Most are related to inherent weakness of a retrospective review, including loss to follow-up. Our study had a small population and a low follow-up making the evaluation of some long-term complications hard.