ЕNDOPROSTHESIS AFTER FRACTURE OF PROXIMAL HUMERUS IN ELDERLY PATIENTS – 3-YEAR EXPERIENCE
Authors: Mitkovski Ivaylo 
Published: December 2021

The proximal humerus is the third most common fracture location in elderly patients after the proximal femoral bone and the distal radial bone. In order to restore the anatomy and bring it as close to normal as possible, blood reposition with internal fixation is a method of choice for unstable fractures. However, surgical treatment is difficult and problematic because of disturbed approach to the fracture and the large fragmentation of pieces. A proximal shoulder bone fracture, which disturbs blood supply of the humeral head, may require placement of prosthesis. Hemiarthroplasty is a logical attitude in such cases, but analysis of functional results and complications has identified a certain number of risk factors limiting indications. Strict analysis of patient characteristics and of fracture type is an essential prerequisite to deciding against treatment by immobilization or osteosynthesis. Results in hemiarthroplasty are primarily dependent on respecting the rules of the art, which aim at stable anatomic osteosynthesis of the surrounding structures so as to restore normal shoulder function. The critical steps are the adjustment of implant height and retroversion, reduction and fixation of tuberosities and good management of the postoperative course. The recent development of fracture-dedicated shoulder implants should improve results. In elderly patients, when local conditions are unsuitable to hemiarthroplasty, a reverse prosthesis may be used, with an adapted surgical technique. Whatever the type of prosthesis, implantation for proximal humerus fracture is a demanding operation with definitive impact on the functional evolution of the shoulder. Following reports of results for shoulder prosthesis in proximal humerus fracture from 1970, several attempts were made to reproduce the encouraging initial findings. Most found good results in terms of pain, but much less satisfactory functional outcome. Analyzing the causes of failure identified risk factors and enabled solutions to be suggested. Among these, one of the first was to select indications, eliminating baseline situations of poor prognosis. Following good results reported in arthropathy involving rotator cuff tear and in revision of hemiarthroplasty for fracture, reverse prostheses were recommended as an alternative attitude in case of proximal humerus fracture in elderly subjects. This particular indication is currently under assessment.This article presents results of a 3-year experience in shoulder endoprothesis after fracture of proximal humerus in elderly patients at Orthopaedics and Traumatology Department, St. Anna General Active Treatment Hospital – Varna, between 2016 and 2018. In this time period, 79 shoulder endoprothesis have been implanted, 68 of which have been actively and carefully observed in the first 12 months of the post-surgery recovery. For the treatment of functional results was utilized Constant Shoulder Score (CSS) that aided following patients’ condition, pain levels, as well as functioning and shoulder movements. Results suggest that in the time span of one year, 51% of the patients show excellent overall recovery state and 38% are in good overall recovery state. These fine results of post-surgery shoulder functioning are in large part due to precise surgery techniques and detailed pre-surgical diagnosis and planning.