1 - INTRODUCTION

At the physiologically old person, in the event of humeral fracture complex (fig. 1), the main difficulty is to obtain a solid and effective synthesis tuberosities. 

The usual ways of assumption of responsibility expose to resorptions, migrations, not-consolidations of those, which the functional result and precipitates sometimes the patient in the dependence ^(1,2).

The reversed prosthesis functions with the only deltoid muscle. The inversion of surfaces ⁽³⁾, the fixity and with the of the center of rotation of the shoulder joint like to the setting in pre-tensioning of the deltoid by lowering of its insertion point ^{(4, 5)} make it possible to increase the arm of lever of this muscle.

With thirteen years a maximum passing, the aim of this work is to know if the reversed implant can find a place within the therapeutic arsenal, in geriatric context, in the event of potential problems of tuberosities

2 - HARDWARE AND METHOD

2.1. The series

From 1993 to 2006, thirty-nine reversed arthroplasties Delta III were carried out by only one operator in fresh traumatology for thirty fractures with four fragments and nine fracture-luxations indexed according to the classification of ⁽⁶⁾, at three men and thirty six women, of median age 75 years (extreme: 58 to 92 years), for ten seven dominant sides (fig. 2). The study of the ground objectified six cases of severe degenerative pathology of the cap of the rotators, three type 1 diabetes and 2, two intricate, three social miseries and three obesities morbid. The characteristics of the fracture, the degrees of osteoporosis, the state of lubricating degeneration muscular according to the criteria of ⁽⁷⁾, but especially the anatomy exact of the neck of the scapula with a view to as well as possible to establish and to the least risk the , were appreciated by means of standard radiographic radiographs and a scanner.

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2.2. Procedure

The intervention was always carried out under general anesthesia in position half-base (fig. 3), by a antéro-side access without osteotomy of the creating a (fig. 4 - fig. 5). The long portion of the biceps was identified by means of a son then divided on the level of its insertion on the (fig. 6). The multiple friable fragments of the tuberosities were inclined by a spreader car-statics, exposing thus perfectly the hinge. The humeral cap was extracted and measured in order to choose a sphere of size 36 or 42 then sent in anatomo-pathology (fig. 7).

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The lower and posterior former excision capsular allowed the positioning of the forked spreader of under horse on the pillar of the scapula, driving back to the bottom the humeral barrel thus offering a perfect sight on (Diagram. 1). With the electric bistoury a cross was drawn on the aforementioned allowing the positioning of the pin discreetly under its equator (fig. 8) in order to shift to the bottom the implantation of the sphere, thus moving away the humeral implant from the neck of the scapula to decrease in so far as to do it the possibility of a local conflict can. The stud of anchoring was drilled. Milling was done manually, in the management guided by the stud until obtaining a bleeding bone under (fig. 9). To facilitate this gesture, it was possible to beforehand abrade with the scraper the cartilage. The was forwarded and impacted with each time a good primary behavior (fig. 10). The quadruple associated screwing was done in a convergent way for the two equatorial screws with seldom a good mechanical resistance of the posterior screw and by seeking the foot of the coracoid process for the higher polar screw. The for the way of the lower polar screw was practiced with low speed of rotation in order to always feel the osseous contact in the pillar with a weak slope and a management marrying the bisector of the angle formed by the two teeth of the spreader of . Indeed, a too downward screw would be quickly in contact with the humeral implant in the event of notch of the pillar, from where a possibility of rupture and unsealing. This stage, after impaction and screwing, the behavior of the implant was to be perfect. Then and only, the remainders of the tuberosities could be . (On the other hand, those were preserved by trying a fixing on a cephalic prosthesis in the event of failing implantation of or with stronger reason in the event of operational fracture of ; the hold of the reversed option becoming illusory). The beforehand selected sphere was screwed by means of the pin guides while remaining always strictly in the axis of the aforementioned in order to obtain a presentation perfectly face-to-face with the (fig. 11). An underspeed first of a quarter of turn could help with obtaining a good starting of screwing (fig. 12).

: Exhibition of

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The humeral preparation did not pose a specific problem, the barrel being directly accessible in the surgical-wound by a movement from adduction bending of the arm (fig. 13). The implants of test allowed the tuning of the retroversion, usually between 10° and 0°, of the voltage and the height (fig. 14). The ideal tuning consisted of the possibility of slipping without difficulty, once the reduction obtained, the pulp of the fifth finger between the sphere and the polyethylene of test at a patient forwarding an optimal curarization (fig. 15). It was advisable at this stage to check the absence of conflict between the humeral implant and the pillar of the scapula and between the metaphysis and the . Then, a capped humeral stem of a metaphysis covered with hydroxyapatite (fig. 16 - fig. 17) was cemented after installation of a diaphyseal obturator (fig. 18). The aileron of the metaphysis allowed the fixing of the long portion of the biceps (fig. 19). The closing of the was done by points separated in wire X after installation from a deep aspiration drain for two days.

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2.3. Post-operative continuations

An immobilization bends with the body by means of Jersey was maintained twenty and one days. An active rehabilitation post-operative always possible pitch in the cases social miseries and of morbid obesity, was begun with the third postoperative day. It was each not very painful and quickly effective time.

The post-operative evaluation rested clinically on the score of Constant and ⁽⁸⁾ and on radiographies of face and profile according to Lamy. The balance-sheets were carried out every month during the first quarter, then every three months during the first year and finally every year.

3 - RESULTS

Because of nine deaths, logics in comparison with the average age of the series, and two lost patients of sight due to removal one in Normandy and the other in Brittany, only twenty-eight case were re-examined with a passing from one to thirteen years.

3.1. Complications

Four complications were noted: two complex regional painful syndromes of type 1 resolvent in six and nine months under medical cure supervised by the team of assumption of responsibility of the chronic pain, an early post-operative infection at three weeks with requiring a resumption of the washing-drainage type preserving the arthroplasty, and a luxation former to one month because of a voluntary of 10° of the humeral implant requiring a reorientation of the aforementioned.

3.2. Clinical outcomes

With nths the average retreat, the rough score of Constant was of 59 points with a score for the opposite shoulder of 81. If the results were good for the pain with an quasi-indolence (14,1 points) and the activity with a conservation of the range (14,3 points), they were average for the dimensioned force at 14,1 points (fig. 20) and disappointing for mobilities with 16,5 points. The active bending and abduction were always higher than 120° with respective scores of 7,5 and 6,5 points safe for the two cases taken again for infection and luxation (fig. 21 - fig. 22). Internal rotation with 1,4 points only made it possible very seldom to put the hand at the level or the top of the (fig. 23). Very weak external rotation with 1,1 points almost always prohibited the setting of the hand behind the head, bends ahead (fig. 24). 

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3.3. Radiographic results

It was interesting to insulate two pennies groups: before and after six years of retreat.

3.3.1. With a passing lower or equal to six years, 16 cases were exploitable:

On the level of , a complete edging of two millimetres thickness appeared at four years of development and remained stable with the last retreat at a man carrying a sphere of size 42. According to the criteria of and ⁽⁹⁾ (Diagram. 2), sixteen notches of the pillar occurred on average, at two years for the seven cases of the type 1 (fig. 25), at four years and three months for the five cases of the type 2 (fig. 26), at five years for the three cases of the type 3 (fig. 27), and at six years in the case of type 4 (fig. 28). Fourteen lower polar osteophytes, nonevolutionary, were noted on average at 2,5 years (extreme 1 to 6 years) (fig. 29 - fig. 30). At the humeral level , appeared two edgings bone-cement (fig. 31) and two lyses at four years, one , the other side one (fig. 32). The edgings and the resorptions were always associated with notches of the pillar of stage two and three (fig. 33).

At six years completed, no recovery for mechanical bankruptcy was to be paid.

diagram: Classification of the notches

 

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3.3.2. With a passing from 7 to 13 years, 12 cases were exploitable:

On the level of , a complete edging of two millimetres thickness was noted at eight years of retreat at there too a man carrying a sphere of size 42 (fig. 34). It was about our first case, addressed in a state of resection of the upper end of the humerus after an attempt at osteosynthesis of a fracture luxation (fig. 35). In front of the complete absence of tuberosities, a reversed arthroplasty was installation. This edging was supplemented at eleven years of a notch stage 2 (fig. 36), then of an unsealing of the by rupture of the polar screw lower than twelve years of development (fig. 37). It profited then from a surgical recovery where an absence of granuloma with foreign body and good osseous inventories were noted allowing the reimplantation of a standard with good primary behavior itself consolidated by three screws; the posterior equatorial screw not being installation for lack of behavior mechanical (fig. 38). Extracted polyethylene did not show signs obvious of wear (fig. 39). At one year of the reintervention, the patient forwarded a recovery of the range, but with a weak score of Constant at 49 points.

Beyond six years of development, it did not appear any new case of notch of the pillar, lower polar osteophyte and edging bone-cement. Only two new humeral lyses were noted ; a and side. No unsealing of stem was noted.

On the whole, the vast majority of the abnormal images unmasked itself before the seventh year, was stable in time and, except for the two cases for early infection and luxation, only a patient forwarded a mechanical failure, at 12 years of retreat, requiring a reintervention.

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4 - DISCUSSION

In context , the usual ways of assumption of responsibility of the complex recent fractures of the humerus reach their limits with disappointing functional results and patients precipitated in the dependence because of the difficulty even of impossibility Re-of fixing the tuberosities in anatomical position. The use of a reversed arthroplasty allows a short functional recovery with conservation of the range without requiring an active co-operation of the patient ⁽¹⁰⁾.

Nevertheless, the reversed arthroplasty knows it also limits which it is advisable not to omit:

1. First of all clinically: if obtaining a functional, stable and painless shoulder is the rule with good mobilities of fronts elevation side and former ⁽¹¹⁾, rotations internal and external are disappointing allowing only seldom the care of hygiene and an easy fuel supply ^{(10) (12)}. The improvement passes, for external rotation by muscular transfers of ⁽¹³⁾ or ⁽¹⁴⁾, and for internal rotation, either by a new prosthetic drawing by decreasing the of the center of rotation and by the humerus ⁽¹⁵⁾, or by the implantation of the humeral stem with a few degrees of ⁽¹⁶⁾. This various news possibilities, alas with a weak passing, technically seems encouraging but complex.

2. Then at the radiographic level: the main issue consists of occurred of a notch of the pillar. The aforementioned for some does not have a clinical repercussion 77 19 19 , which is not the case for others ⁽²⁰⁾. Its etiology is discussed. For ⁽²¹⁾, it would be due to microcomputer-movements of the lower polar screw because of a low mechanical resistance, while for Werner ⁽¹⁷⁾ it would be about a conflict between the pillar of the scapula and the edge of the humeral cup, raised when the arm is along the body and at the time of the movements   of adduction (Diagram. 3). The significance of a stage 4 is not established. For ⁽²²⁾, it is about an unsealing; assumption not retained by Wallace and Werner (12-17). For ⁽²³⁾, an unsealing can be marked only if there exists an edging around the fastening screws of . The prevention of which has occurred of a notch would pass, neither by the implantation of with a light slope in the vertical plan, neither by the use of D-hausseur humeral, nor by the use of a sphere of large diameter, but by a lowering of the implantation of ⁽²⁴⁾ or by a new prosthetic drawing ⁽¹⁵⁾. These possibilities encounter difficulties of fixing in the event of poor osseous inventories and a low primary behavior to the impaction of the ⁽¹²⁾. Our experiment in fresh traumatology leaves us think that it seems to exist two types of notches; notches isolated and stable of mechanical origin and evolutionary notches in space and time always associated with images of humeral osseous lysis. Does there exist a passage from one type to another?

Diagram : Conflict causes notch.

3. Finally the procedure is demanding and exposes to complications. During the intervention, can occur a nervous attack for which it will be necessary to hope for a spontaneous cure, a fracture of the humeral diaphysis which will be discussed classically by external extension to the level of the arm of the articular antéro-external access, but especially, he is to be feared a fracture or a perforation of kind in the installation of an hémi-arthroplasty: of or major importance of the realization a scanner before the intervention in order to as well as possible to define the site of implantation of the (24-25). Into post-operative, the common complications for this type of implant occurred of an hematoma because of important dead space created and voluntary or involuntary early rehabilitation ⁽¹⁶⁾. It is thus important to look after the hemostases particularly, of always set up an aspiration drainage, and to position an effective application for several days. For the same reasons, it is to be feared an infection, whose rate of occurred is higher than the rates observed for the cephalic arthroplasties, with germs of the type Acnes (12-16). The depression of the humeral stem is to be feared with time. For that, in context of osteoporosis, it is advised to establish a cemented stem ⁽¹⁶⁾. The die-assembly between the stem and the metaphysis and the underspeed between and the sphere are problems solved since 1995. Luxation is of diagnosis difficult because some pass unperceived particularly to the subjects to strong body index of mass. Its search passes by the realization of a trans-thoracic profile ⁽²⁶⁾. The causes are, either a muscular defect of voltage and then requires the installation of D-hausseur ⁽¹⁶⁾ associated or not with the use of a sphere of size 42, or in the interposition with the lower pole of of soft-tissues or remainders of the tuberosities (15-24). For some, the antéro-side channel would be less provider of luxation than the delto-pectoral channel ⁽²⁷⁾. In our experiment, our only case of luxation occurred by a voluntary excess of in order to try to gain in internal rotation. Its prevention passes the systematic use of the implants of test thus allowing the height adjustments and in version ⁽¹⁵⁾. The absence of tuberosities giving an easy access to the hinge and the use of a stem cemented necessary in context of osteoporosis allow obtaining all the types of tuning. It is necessary especially, there like elsewhere, to insist on the perfect respect of the procedure because this surgery in little tested hands exposes to a very strong complication rate 98 58 79

5 - CONCLUSION 

The advantage of the reversed prosthesis is to avoid the complications related to the synthesis of the tuberosities. In context , for a recent fracture proximal end of the humerus complexes, when a prosthetic solution is adopted, this study carries us to conclude that:

1. It is necessary to know to privilege the use of a cephalic joint replacement with solid and anatomical reintegration of the tuberosities, because it is the only possibility which allows the restoration of rotations authorizing a fuel supply and correct care of hygiene.

2. If the tuberosities are not mechanically usable, it is necessary to be directed towards a reversed prosthesis, which will get indolence, force and active front elevation.

3. Practically, it will be advisable to have for provision in operational room the two types of implant.

4.  The improvement of the weakness of the results in rotation will pass most probably in the near future by the realization of muscular transfers. The reduction in the number of the worrying radiographic pictures (85% of the cases to nths the average retreat) should pass it by the amendment of the positioning of the prosthetic parts and/or a new drawing of those.

5.  The validation of the use of the implant reversed in fresh traumatology will require other work with a passing even more important.