Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty.

UNLABELLED: Our goal was to analyze the results of unconstrained shoulder replacement in a large series of sequelae of proximal humeral fractures in order to validate a previously described surgical classification. In a multicenter study, we retrospectively evaluated 203 patients with sequelae of proximal humeral fractures who were treated with a nonconstrained modular and adaptable prosthesis. The mean followup was 42 months (range, 24-96 months). We identified 137 impacted fractures with humeral head collapse or necrosis (Type 1 sequelae), 25 unreducible dislocations or fracture-dislocations (Type 2), 22 nonunions of the surgical neck (Type 3), and 19 severe tuberosity malunions (Type 4). Results of nonconstrained shoulder arthroplasty for the treatment of Type 1 and Type 2 sequelae were predictably good because no greater tuberosity osteotomy was performed. The distorted anatomy was accepted, and both the prosthesis and technique were modified accordingly. Total shoulder arthroplasty yielded better results than hemiarthroplasty. Patients with Type 3 or Type 4 sequelae had poor functional results with nonconstrained arthroplasty because greater tuberosity osteotomy was needed. This study validates our fracture sequelae classification. We no longer use unconstrained prostheses in Type 3 and Type 4 fracture sequelae and propose peg bone grafting or low-profile fracture prosthesis for patients with Type 3 sequelae and reverse arthroplasty for those with Type 4 sequelae. LEVEL OF EVIDENCE: Prognostic study, level IV (case series). See Guidelines for Authors for a complete description of levels of evidence.