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J Shoulder Elbow Surg (2012) 21, 507-513

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Proximal humeral malunion treated with reverse shoulderarthroplasty

Matthew Willis, MDd, William Min, MDb, Jordan P. Brooks, BSc, Philip Mulieri, MD, PhDa,Matthew Walker, MDa, Derek Pupello, MBAc, Mark Frankle, MDa,*

aFlorida Orthopaedic Institute, Tampa, FL, USAbDepartment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USAcFoundation for Orthopaedic Research and Education, Tampa, FL, USAdTennessee Orthopaedic Alliance, Nashville, TN, USA

Background: The purpose of this study was to determine the outcomes of patients with proximal humeralmalunions treated with reverse shoulder arthroplasty (RSA).Materials and methods: Sixteen patients were treated with RSA for sequelae of a proximal humeral frac-ture with a malunion. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, SimpleShoulder Test, visual analog scale [VAS] score for pain and function, range of motion, and patient satis-faction) and radiographs were evaluated at a minimum follow-up of 2 years. Wilcoxon signed-rank testswere used to analyze preoperative and postoperative data.Results: All patients required alteration of humeral preparation with increased retroversion of greater than30�. The total ASES score improved from 28 to 63 (P ¼ .001), ASES pain score from 15 to 35 (P ¼ .003),ASES functional score from 15 to 27 (P ¼ .015), VAS pain score from 7 to 3 (P ¼ .003), VAS functionscore from 0 to 5 (P ¼ .001), and Simple Shoulder Test score from 1 to 4 (P ¼ .0015). Forward flexionimproved from 53� to 105� (P ¼ .002), abduction from 48� to 105� (P ¼ .002), external rotation from5� to 30� (P ¼ .015), and internal rotation from S1 to L3 (P ¼ .005). There were no major complicationsreported. Postoperative radiographic evaluation showed 2 patients with evidence of notching and 1 patientwith proximal humeral bone resorption.Conclusion: RSA is indicated for treating the most severe types of proximal humeral fracture sequelae.The results of RSA for proximal humeral malunions with altered surgical technique yield satisfactoryoutcomes in this difficult patient population.Level of evidence: Level IV, Case Series, Treatment Study.� 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Reverse shoulder arthroplasty; proximal humeral malunion

The treatment options, outcomes, and potential compli-cations of proximal humeral fractures have been exten-sively described in the literature. However, the management

pproved by Western Institutional Review Board 1106127.

uests: Mark Frankle, MD, Florida Orthopaedic Institute,

m Pkwy, Temple Terrace, FL 33637-0925, USA.

ss: frankle@pol.net (M. Frankle).

ee front matter � 2012 Journal of Shoulder and Elbow Surgery

.2011.01.042

of their complications has become a more prevalent topic astheir incidence steadily increases because of the increasedactivity and longevity of the geriatric population.5 As such,the rate of proximal humeral malunions will likely increaseas more fractures are encountered and managed. Thesemalunions can result in pain and significantly affect thefunctional outcome of this patient population.

Board of Trustees.

508 M. Willis et al.

The treatment of proximal humeral nonunions hasincluded nonoperative management, osteotomies, soft-tissue repairs, arthroscopic management, total shoulderarthroplasty, hemiarthroplasty, or arthrodesis. However, theuse of reverse shoulder arthroplasty (RSA) for treatment ofproximal humeral malunions has not been extensivelydescribed in the literature. The purpose of this study was toassess the surgical technique and outcomes for the treat-ment of proximal humeral malunion with RSA.

Materials and methods

Between January 2005 and February 2008, 20 patients underwentRSA for malunion of a proximal humeral fracture at our institu-tion. Sixteen patients with preoperative data and a minimum 2-yearclinical follow-up (mean, 37 months; range, 24-62 months) wereincluded in this study. Three patients who did not return for their2-year follow-up and could not be contacted were excluded. Onepatient died before completing follow-up. There were 12 womenand 4 men whose mean age was 65 years (range, 52-83 years). Amean of 0.75 surgical procedures were performed at outsidefacilities before RSA (range, 0-3). Indications for surgery weresevere pain and/or significant functional limitations (active eleva-tion <90�) due to a proximal humerus malunion with failedconservative management with a proximal humeral deformity. Allpatients had a preoperative evaluation, including a digital videorecording of their active range of motion, which was measured byan independent third party using a digital goniometer. Patients alsofilled out a standard questionnaire that included the AmericanShoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test(SST) score, visual analog scale (VAS) score for pain and function,and Short Form 36 score. In addition, each patient had completeradiographic series (true anteroposterior, axillary, internal andexternal rotation, and scapular-Y views) and a computed tomog-raphy (CT) scan of the affected shoulder to evaluate bone stock anddeformity. By use of the CT scan, 3-dimensional (3D) recon-structions were performed (Fig. 1). Plastic 3D models of eachmalunion were produced by use of the data from these CT scans toassist with understanding the deformity.

Operative technique and postoperative protocol

All procedures were performed through a standard deltopectoralapproach by the senior author using a single implant (ReverseShoulder Prosthesis; DJO Surgical, Austin, TX, USA). Thefundamentals of this technique have been previously described,including scar tissue release from the subcoracoid, subacromial,and subdeltoid spaces as well as anterior and inferior capsuleexcision.15 However, there were some salient variations inhumeral preparation. First, rather than compromise bone stock byosteotomy of the bony deformity, the soft tissue was released togain the appropriate exposure and/or range of motion. Forexample, if the greater tuberosity malunion prevented adequateexposure of the glenoid, even after freeing of the rotator cuff fromsurrounding scar tissue, the rotator cuff was released off thegreater tuberosity with electrocautery. If this was necessary, someposterior rotator cuff was left to allow for preservation of someexternal rotation. The humeral canal was prepared by a cementedtechnique as previously described. The only difference was that

the bony deformity was accommodated by centering the socketwithin the deformity so as to minimize the distance from the boneto the socket in every direction. To accomplish this, the socketreamers were often used without the humeral trial stem, whichwould constrain the reamer position. Thus, the socket dictated theposition of the final implant, and the stem was usually downsizedso that it could be freely positioned within the canal in aneccentric manner. Version of the socket was also altered toaccommodate the bony deformity and always resulted in increasedretroversion of the humeral component beyond the standard 30�

present in the system instrumentation. This version was judgedintraoperatively by positioning the head cut and reamers tomaintain the malunited tuberosities while minimizing excessiveretroversion. No attempt was made to perform osteotomy of themalunited tuberosities or remaining proximal humerus. However,after implantation of the humeral components, excess bone wasremoved by use of a rongeur to improve the impingement-free arcof motion and theoretically decrease ‘‘levering out’’ as a mecha-nism of dislocation. In 1 case, the implant had to be modified aswell. Preoperatively, for this case, a virtual model and the CT scanand radiographs were used to template the final position of theimplant. Rather than performing osteotomy of the greater tuber-osity with the remaining attached rotator cuff, we felt that modi-fication of the implant itself would allow the best postoperativefunction (Fig. 2). Templating radiographs may be the most readilyavailable tool to assist in preoperatively determining implantposition.

Clinical and radiographic assessment

Clinical outcomes were measured both preoperatively and post-operatively through patient questionnaires. Data obtained in thisway included the ASES score, SST score, VAS scores for pain andfunction, Short Form 36 score, and overall patient satisfaction(excellent, good, satisfactory, or unsatisfactory). Range of motionwas determined by independent third-party evaluation of digitalvideos of each patient obtained preoperatively and postoperativelyusing a digital goniometer.

Preoperative radiographs were evaluated for the type of mal-union according to the classification of Boileau et al.9 CT scanswere used mainly for preoperative planning to further characterizethe deformity and any bone deficiency. The most recent post-operative radiographs were assessed for humeral and glenoidbaseplate loosening. These radiographs were also evaluated forevidence of scapular notching (graded according to Sirveauxet al23), dislocation, and hardware failure.

Statistical analysis

Data obtained from preoperative and postoperative questionnaireswere compared by use of Wilcoxon signed-rank tests because thedata were nonparametric. The level of statistical significance wasset at less than .05.

Results

Overall, 10 patients rated their outcomes as excellent(62.5%), 3 as good (18.75%), and 3 as satisfactory (18.75%).TheASES scores preoperatively and postoperatively showed

Figure 1 (A) Preoperative radiograph of Boileau type 4 malunion. (B) Preoperative CT scan. (C) Preoperative virtual model.(D) Postoperative radiograph. One should note the downsized humeral stem placed in valgus to accommodate the deformity.

RSA for proximal humeral malunion 509

statistical significance. The total ASES score preoperativelyhad amean of 28, which improved to 63 postoperatively (P¼.001). The ASES pain score improved from 15 preopera-tively to 35 postoperatively (P ¼ .003). The ASES functionscore also improved, from 15 preoperatively to 27 post-operatively (P ¼ .015).

The VAS pain score improved from a mean of 7preoperatively to 3 postoperatively (P ¼ .003). The VASfunction score also improved, from 0 preoperatively to 5postoperatively (P ¼ .001). Similarly, the SST resultsshowed an improvement from 1 preoperatively to 4 post-operatively (P ¼ .005). Forward flexion improved from 53�

to 105� (P ¼ .002). Abduction improved from 48� to 105�

(P ¼ .002). External rotation improved from 5� to 30�

(P ¼ .015), and internal rotation improved from S2 to L3 onaverage (P ¼ .015).

Alteration in surgical technique

In all cases, alteration of humeral preparation was required,resulting in a more difficult surgical procedure. All humeralcomponents were retroverted greater than the standard 30�

previously reported for the device to accommodate thebony deformity present. Intraoperatively, the sizes of theglenosphere that were used ranged from 32 mm (�4 mmoffset) to 40 mm (�4 mm offset). The glenosphere size wasmade as large as necessary to prevent dislocation due toinadequate soft-tissue tension or bony impingement. The

Figure 2 (A) Preoperative radiograph of Boileau type 4 malunion. (B) Preoperative radiograph of possible placement of humeral stem.(C) Preoperative virtual template of possible placement of humeral stem. Excessive bony impingement is noted. (D) Preoperative virtualtemplate with modified humeral stem. Bony impingement is minimized. (E) Postoperative radiograph.

Table I Proximal humeral malunion classification by Boileau et al9

Type Description Notes

1 (n ¼ 6) Cephalic collapse or necrosis Intracapsular, impacted2 (n ¼ 0) Chronic dislocation or fracture-dislocation An articulating joint can be reconstructed3 (n ¼ 1) Nonunion of surgical neck Extracapsular, poor results with osteotomy4 (n ¼ 9) Severe tuberosity malunions Poor results with osteotomy

510 M. Willis et al.

most common size used was the 32 (�4) glenosphere. On 1occasion, the humeral stem had to be modified (Fig. 2).

Radiographic analysis

Table I summarizes the types of fracture sequelae treatedaccording to the grading system of Boileau et al.9 Themajority were type 4 (9 of 16) and type 1 (6 of 16). Therewas 1 type 3. No significant differences in outcomes werefound between these groups given the numbers available.

The status of the rotator cuff was graded according to theclassification of Goutallier et al.18 The mean grade for the

subscapularis was 1.69 (range, 1-3). The mean grade for thesupraspinatus was 1.75 (range, 0-3). The mean grade for theinfraspinatus was 1.44 (range, 0-3). Of the patients, 13% (2 of15) had grade 3 for both the subscapularis and supraspinatusand 7% (1 of 15) had grade 3 for the infraspinatus. The meangrade for the teres minor was 0.06, with only 1 patient havinggrade 1 fatty atrophy and the rest having no atrophy.With thenumbers available, there were no significant differences infatty atrophy noted among the malunion types.

Analysis of postoperative radiographs found no instancesof hardware loosening, failure, or instability. There were2 cases (12.5%) with lucency around the humeral socket that

RSA for proximal humeral malunion 511

were non-progressive and 1 case with proximal humeralresorption. Notching was seen in 2 cases (12.5%) and did notoccur concurrently with humeral lucency. The notches wereminimal (grade 1) and involved only the inferior neck. Therewas no baseplate loosening noted.

Complications

There were no complications reported for this group ofpatients with the exception of radiographic findings asdescribed above. One patient was found to have an infec-tion intraoperatively at the time of revision and was treatedwith debridement, 1-stage implantation, and postoperativeantibiotics with no recurrence of infection by use ofa technique previously described by Cuff et al.12

Discussion

Our study found that with alteration in surgical technique,the clinical and radiographic outcomes of patients treatedwith RSA for proximal humeral malunion were satisfactoryin the short term.

A progressive increase in proximal humeral fracturessince the 1950s has occurred, and though not reported,a corresponding increase in proximal humeral malunions isalso expected.5 Although a majority of proximal humeralfractures are treated nonoperatively, those that developproximal humeral malunions can have significant func-tional deficiencies and pain. Further treatment at this pointis often warranted, and treatment must be tailored specifi-cally to the patient’s functional level, medical comorbid-ities, pre-existing pathologies (such as rotator cuff integrityand pre-existing glenohumeral arthritis), and expectations.

Treatments of proximal humeral malunions with humeralheadepreserving techniques have been discussed exten-sively in the literature. Proposed techniques include osteot-omies, acromioplasty, soft-tissue surgeries, arthrodesis,and interposition arthroplasty. However, humeral headepreserving techniques have yielded variable results, reflect-ing the complicated pathology associated with thiscondition.2,4,6,10,19,21,24 The application of humeral headesacrificing techniques has been investigated by use of variousshoulder prosthetic devices.1,6-10,17,20-22 Antu~na et al1 repor-ted on 50 shoulders with proximal humeral malunions in 50patients who were treated with hemiarthroplasty or totalshoulder arthroplasty and followed up for a mean of 9 years.In this group, 50% (25 patients) had an unsatisfactory resultbased on the Neer result rating. Beredjiklian et al6 retros-pectively reviewed 39 patients treated operatively for prox-imal humeral malunions. This was a heterogeneous treatmentgroup consisting of arthroplasty, arthrodesis, and bonyand soft-tissue procedures. At a mean of 44 months post-operatively, the results were satisfactory in 27 patients (69%)and unsatisfactory in the remaining 12 (31%). Of the patients

who had a satisfactory result, 26 (96%) had complete opera-tive correction of all osseous and soft-tissue abnormalities. Ofthe patients who had an unsatisfactory result, only 4 hadcomplete operative correction of these abnormalities (P <.0001). Incongruity of the glenohumeral joint was found at thetime of presentation in 26 patients (67%), and 22 of thesepatients had the incongruity corrected with either totalshoulder arthroplasty or hemiarthroplasty. Of these patients,17 (74%) had satisfactory results. The authors concluded thatoperativemanagement of these patients is successful only if allosseous and soft-tissue abnormalities are corrected at the timeof the operation.

To date, very few authors have examined the role of RSAin the treatment of proximal humeral malunions, particularlyin patients with forward elevation less than 90�. Boileauet al9 examined their results of total shoulder arthroplasty orhemiarthroplasty for proximal humeral malunions and notedthat postoperative Constant scores were excellent in 11 cases(16%), good in 19 (26%), fair in 18 (25%), and poor in 23(33%). There were 18 complications (27%), and 59 of 70patients (81%) stated that they were satisfied with the resultdespite these poor Constant scores. The most significantfactor affecting functional outcome was greater tuberosityosteotomy. All patients who underwent a greater tuberosityosteotomy had either fair or poor results and did not regainactive elevation above 90�. The authors concluded thata greater tuberosity osteotomy is the most likely reason forpoor and unpredictable results after shoulder arthroplasty forthe treatment of proximal humeral malunions and thatprosthetic replacement should be performed without anosteotomy of the greater tuberosity when possible.

Boileau et al7,8 revisited a larger series of the samepatient group in 2006 and again in 2008, this time exam-ining the role of RSA. In 40 patients treated with RSA forproximal humeral malunions, the mean Constant score was53 with mean elevation of 114�. External rotation for thisgroup averaged 4�, with internal rotation to the sacrum.These values were similar to those in the heterogeneousgroup of malunions treated with total shoulder arthroplastyor hemiarthroplasty previously examined by Boileau et al.9

This group had a mean Constant score of 57, with meanelevation of 112�. External rotation for this group averaged30�, a significant improvement, and internal rotation wasnot reported. For severe proximal humeral malunions, ortype 4 sequelae as classified by Boileau et al, the resultswere different. The mean Constant score was 55 in 18patients treated with RSA, whereas in 17 patients treatedwith an unconstrained prosthesis, it was 42. Boileau et alrecommended RSA instead of total shoulder arthroplasty/greater tuberosity osteotomy for this patient population.They also recommended that surgeons should accept thedistorted anatomy of the proximal humerus and adapt theprosthesis (with modular implants) and their technique tothe modified anatomy.

There are several notable differences between the datafrom previous studies evaluating RSA for proximal humeral

512 M. Willis et al.

malunions and our data. First, data comparing the 2 pop-ulations in other studies included only Constant score andrange of motion, and preoperative elevation was not dis-cussed. There was no patient with preoperative activeelevation greater than 90� in our population. This may berelated, at least in part, to the status of the rotator cuff, whichwas not evaluated in previous studies. As shown in this study,some fatty atrophy was present in nearly all patients witha malunion regardless of Boileau type. Finally, externalrotation improved significantly in our study, and this may berelated to the use of a lateral-offset prosthesis, preservation ofthe posterior rotator cuff, or additional retroversion used.These results have been duplicated in several other studiesusing this prosthesis.11,12,15

The decision to treat proximal humeral malunions withRSA instead of hemiarthroplasty or total shoulder arthro-plasty is supported by several different factors. First,regardless of the Boileau type of humeral malunion, somebony asymmetry is usually present. Coupled with variousdegrees of fatty atrophy of the rotator cuff, there may beuneven forces placed across the glenoid component ofa total shoulder arthroplasty. These uneven forces may leadto early failure due to the previously described ‘‘rocking-horse’’ mechanism.3,16 Longer-term studies will be neces-sary to determine outcomes of total shoulder arthroplastyfor proximal humeral malunion. In addition, elevation maybe hindered both preoperatively and postoperatively bybony or soft-tissue abnormalities present in proximalhumeral malunions. By use of RSA, the deltoid mayfunction as the primary elevator without the need fora normally functioning or anatomically positioned rotatorcuff. We have yet to determine the ideal setting for totalshoulder arthroplasty in the presence of proximal humeralmalunion, but we believe that it may be appropriate forlimited bony deformity and minimal fatty atrophy noted onpreoperative CT scans.

In the treatment of proximal humeralmalunionswithRSA,there are several important variations with regard to preop-erative planning aswell as intraoperative technique comparedwith other indications forRSA.Careful preoperative planningwith CT scans, including 3D reconstructions when available,can assist the surgeon in understanding the deformity. Theimportance of obtaining these CT scans to better understandproximal humeral anatomy has been emphasized by severalauthors.2,13,14Given the inconsistent results in the literature ofosteotomy to correct deformity, we elected not to performosteotomies. Instead, the soft tissue was released to gain theappropriate exposure and/or range of motion. We tried toaccommodate for the abnormal bony anatomy by centeringthe socket within the deformity so as tominimize the distancefrom the bone to the socket in every direction and improve theimpingement-free arc of motion. Surgeons should adopt theversion of the humeral component to the additional retro-version present. Lateralization of the glenosphere allowsfor increased retroversion of the humeral stem withoutimpingement due to the increased offset. In our experience,

impingement against the coracoid with internal rotation wasnot a problem with this technique. The surgeon cannotunderestimate the increased difficulty of adopting the pros-thesis to the deformity. Similar to previously publishedresults, our outcomes, though improved, were generallyinferior to those achieved byRSA for other pathologic entitiessuch as massive cuff tears and rotator cuff arthropathy.7-9,11

Furthermore, although no major complications were repor-ted in this series, we believe this was related to low patientnumbers and did not accurately reflect the true likelihood ofobserving a complication with this technique.

Some weaknesses of this study include failure to accu-rately determine the mean degree of pathologic retroversionpresent in these deformities. Even with plastic 3D models,accurate measurement of pathologic displacement of frac-ture fragments including the humeral head could not beperformed given the severity of the malunions. Had the 3DCT scans included the elbow, a better estimation of path-ologic retroversion may have been possible. An additionalweakness is the smaller sample size, although with thenumbers available, statistical significance was achieved inall measured variables. Longer follow-up will betterdetermine the long-term outcomes of these patients.

Conclusions

The use of RSA for proximal humeral malunions istechnically challenging, even for the experiencedshoulder surgeon. Careful patient selection and thor-ough preoperative planning are essential factors inenabling good clinical outcomes. Furthermore, the useof 3D CT scans can assist in planning surgical techniqueand strategy. Surgical technique frequently must bealtered to accommodate bony deformity. The results ofRSA for proximal humeral malunions, though not asgood as those achieved for other pathologic conditions,yield satisfactory outcomes in this difficult patientpopulation.

Disclaimer

This study was funded by grants from DJO Surgical.Dr. Frankle receives research support and royalties

and is a paid consultant for DJO Surgical.Mr. Pupello receives research support from DJO

Surgical.Mr. Brooks receives research support from DJO

Surgical.The other authors, their immediate families, and any

research foundations with which they are affiliated havenot received any financial payments or other benefitsfrom any commercial entity related to the subject of thisarticle.

RSA for proximal humeral malunion 513

References

1. Antu~na SA, Sperling JW, Sanchez-Sotelo J, Cofield RH. Shoulder

arthroplasty for proximal humeral malunions: long-term results.

J Shoulder Elbow Surg 2002;11:122-9. doi:10.1067/mse.2002.120913

2. As’ad M, Thet MM, Chambler AF. Arthroscopic treatment for mal-

union of a head-splitting proximal humeral fracture: the need for

adequate initial radiologic investigation. J Shoulder Elbow Surg 2007;

16:e1-2. doi:10.1016/j.jse.2006.08.003

3. Barrett WP, Franklin JL, Jackins SE, Wyss CR, Matsen FA III. Total

shoulder arthroplasty. J Bone Joint Surg Am 1987;69:865-72.

4. Benegas E, Zoppi Filho A, Ferreira Filho AA, Ferreira Neto AA,

Negri JH, Prada FS, et al. Surgical treatment of varus malunion of the

proximal humerus with valgus osteotomy. J Shoulder Elbow Surg

2007;16:55-9. doi:10.1016/j.jse.2006.04.011

5. Bengner U, Johnell O, Redlund-Johnell I. Changes in the incidence of

fracture of the upper end of the humerus during a 30-year period.

A study of 2125 fractures. Clin Orthop Relat Res 1988:179-82.

6. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative

treatment of malunion of a fracture of the proximal aspect of the

humerus. J Bone Joint Surg Am 1998;80:1484-97.

7. Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C. Proximal

humerus fracture sequelae: impact of a new radiographic classification

on arthroplasty. Clin Orthop Relat Res 2006;442:121-30. doi:10.1097/

01.blo.0000195679.87258.6e

8. Boileau P, Neyton L. Reverse shoulder arthroplasty in proximal

humerus fracture sequelae. Constrained or nonconstrained prosthesis?.

In: Boileau P, Walch G, Mole D, Favard L, Levigne C, Sirveaux F,

et al., editors. Shoulder concepts 2008. Proximal humeral fracture

sequelae. Montpellier, France: Sauramps Medical; 2008. p. 265-9.

9. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R.

Shoulder arthroplasty for the treatment of the sequelae of fractures of

the proximal humerus. J Shoulder Elbow Surg 2001;10:299-308.

10. Craig EV. Open reduction and internal fixation of greater tuberosity

fractures, malunions and nonunions. In: Craig EV, editor. Master

techniques in orthopaedic surgery: the shoulder. New York: Raven

Press; 1995. p. 289-307.

11. Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder

arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint

Surg Am 2008;90:1244-51. doi:10.2106/JBJS.G.00775

12. Cuff DJ, Virani NA, Levy J, Frankle MA, Derasari A, Hines B, et al.

The treatment of deep shoulder infection and glenohumeral instability

with debridement, reverse shoulder arthroplasty and postoperative

antibiotics. J Bone Joint Surg Br 2008;90:336-42. doi:10.1302/0301-

620X.90B3.19408

13. Edelson G, Kelly I, Vigder F, Reis ND. A three-dimensional classifi-

cation for fractures of the proximal humerus. J Bone Joint Surg Br

2004;86:413-25. doi:10.1302/0301-620X.86B3.14428

14. Edelson G, Saffuri H, Obid E, Vigder F. The three-dimensional

anatomy of proximal humeral fractures. J Shoulder Elbow Surg

2009;18:535-44. doi:10.1016/j.jse.2009.03.001

15. Frankle M, Levy JC, Pupello D, Siegal S, Saleem A, Mighell M, et al.

The reverse shoulder prosthesis for glenohumeral arthritis associated

with severe rotator cuff deficiency. a minimum two-year follow-up

study of sixty patients surgical technique. J Bone Joint Surg Am 2006;

88(Suppl 1, Pt 2):178-90. doi:10.2106/JBJS.F.00123

16. Franklin JL, Barrett WP, Jackins SE, Matsen FA III. Glenoid loosening

in total shoulder arthroplasty. Association with rotator cuff deficiency.

J Arthroplasty 1988;3:39-46.

17. Gerber C. Reconstructive surgery following malunion of fractures

of the proximal humerus in adults [in German]. Orthopade 1990;19:

316-23.

18. Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S.

Influence of cuff muscle fatty degeneration on anatomic and functional

outcomes after simple suture of full-thickness tears. J Shoulder Elbow

Surg 2003;12:550-4. doi:10.1016/S1058274603002118

19. Hinov V, Wilson F, Adams G. Arthroscopically treated proximal

humeral fracture malunion. Arthroscopy 2002;18:1020-3. doi:10.

1053/jars.2002.36488

20. Mansat P, Guity MR, Bellumore Y, Mansat M. Shoulder arthroplasty

for late sequelae of proximal humeral fractures. J Shoulder Elbow

Surg 2004;13:305-12. doi:10.1016/S1058274604000370

21. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD.

Innovations in the management of displaced proximal humerus frac-

tures. J Am Acad Orthop Surg 2007;15:12-26.

22. Siegel JA, Dines DM. Techniques in managing proximal humeral

malunions. J Shoulder Elbow Surg 2003;12:69-78. doi:10.1067/mse.

2002.123902

23. Sirveaux F, Oudet D, Huguet D, Lautmann S. Grammont inverted total

shoulder arthroplasty in the treatment of glenohumeral osteoarthritis

with massive and nonrepairable cuff rupture. In: Walch G, Mole D,

editors. 2000 Protheses d’epaule: recul de 2 a 10 ans. Paris, France:

Sauramps Medical; 2001. p. 247-52.

24. Solonen KA, Vastamaki M. Osteotomy of the neck of the humerus for

traumatic varus deformity. Acta Orthop Scand 1985;56:79-80.