Operative Techniken
Orthop Traumatol 2011 · 23:21–28
DOI 10.1007/s00064-010-0012-8
Online publiziert: 18. Februar 2011
© Springer-Verlag 2011
Redaktion
A.B. Imhoff, München
Zeichnungen
R. Himmelhan, Heidelberg
Introductory remarks
Proximal humeral fractures are among
the most common fractures. Nondis-
placed fractures can be treated non-­
operatively, but displaced fractures are
generally treated­operatively. The majority­
of these displaced fractures can be treated
by osteo­synthesis, but there are still indi-
cations for primary arthroplasty [6].
The outcome of primary fracture
­arthroplasty of the shoulder is strongly
related to healing of the tuberosities upon
the prosthesis [1, 8]. In a multicenter study
using the first generation Articula (Ma-
thys Ltd., Bettlach) prosthesis, the Con-
stant score (CS) averaged 54 in ­patients
where the tuberosities had healed. How-
ever, if (anatomical) healing could not
bedemonstrated, the mean CS was
40.3 points. In only 36 of 111 patients was
anatomical tuberosity healing obtained.
In a subsequent study [7], we demon-
strated that the inclusion of a circumferen-
tial stainless steel cable, which compresses
the tuberosities upon a voluminous meta­
physeal part, significantly increases the
rate of anatomical tuberosity healing. In a
historical series where the tuberosity fixa-
tion was realized using sutures alone, only
36% of anatomical healing and 20% of mal-
united tuberosities were obtained. Includ-
ing an encircling steel cable, but still using
the first generation Articula prosthesis,­
these results were improved and 58% of
anatomical healing and 25% of malunions
were obtained.
S. Nijs1 · F. Reuther2 · P. Broos1
1 Department of Traumatology, UZ Leuven
2 Klinik für Unfallchirurgie und Orthopädie, DRK Kliniken Berlin, Köpenick
Primary fracture arthroplasty
of the proximal humerus using
a new and freely adjustable
modular prosthesis combined
with compression osteosynthesis
of the tuberosities
To further improve the results, a sec-
ond generation of the Articula shoulder­
prosthesis was developed, the Affinis
Fracture prosthesis (Mathys Ltd, Bett­
lach). The second generation prosthe-
sis has many improvements over the ori­
ginal. First, the refixation of the tuberosi-
ties is facilitated by drilling a second hole,
close to the location of the insertion of the
supraspinatus tendon, and by reshaping
the shoulder of the prosthesis. The shape
of the metaphyseal part is better adapted
to the form of the so-called missing fifth
fragment. This is the area of compressed
spongeous bone always present in com-
plex fractures of the proximal humerus.
Second, in order to obtain a stable and
anatomic fixation, the volume and shape
of the metaphyseal parts of the prosthe-
ses have been redesigned, based on the 3D
reconstruction of CT scans of fractured
proximal humeri. Third, a rough micro-
structure of the metaphyseal part has been
added that, together with the spiked ma­
crostructure, allows for extremely stable
primary fixation of the tuberosities up-
on the prosthesis. Fourth, the prosthesis
is coated with CaP (calcium–phosphate),
which has proven to be effective in pro-
moting bone ingrowth in extreme arthro-
plastic circumstances. Fifth, one now has
the option of using centric ceramic heads
or eccentric metal heads if the circum-
stances allow for adaptation to the recon-
structed tubercular anatomy. The strength
of the first generation prosthesis, the ease
of the surgical procedure, the freely cor-
Operative Orthopädie und Traumatologie 1 · 2011  | 21
rectable retroversion, and a height ad-
justment of 1 cm after cementation of the
stem are further assured.
Surgical principle
F Anatomical reconstruction of the
head–shaft relations (height and  
re­troversion)
1Height based on:
1Metaphyseal extension of the head
fragment
1Head tuberosity distance between
5 and 10 mm
1Reconstruction of the gothic arch
1Head–pectoralis major distance
(PMT 5.6±0.5 cm)
1Retroversion based on:
1Anatomical retroversion of about
25° relative to the axis of the forearm
1Contralateral retroversion
1The head facing the glenoid in
neutral position of the forearm
F Anatomical fixation of the tubero-
sities. In order to obtain an anatomi-
cal reconstruction, two different  
sizes of the metaphyseal part are
available, making it possible to fill out
the fifth fragment (compression area
after impaction of the shaft in the  
metaphysis). An additional fixation
hole is available at the supraspinatus
footprint, facilitating anatomical  
reposition of the greater tuberosity.
F Stable fixation of the tuberosities
using an encircling compression  
cable without graft interposition.  

The enhanced stability combined
with the CaP coated, irregular surface
results in higher healing percentages
of the tuberosities.
F Objectives:
1Pain-free shoulder
1Acceptable range of motion
(to perform ADL activities)
1Maintain the pre-existing level of
independence
1Long-lasting solution (not prone to
revision surgery)
F Shortcomings:
1Remains difficult to reach anatomic
reconstruction
1Healing of the tuberosities not
obtained in all patients
1Even in cases of healed tuberosities,
function is on average limited
1Long and intensive rehabilitation
necessary
Advantages
F Easy and reproducible technique
F Modular design enabling the combi-
nation of three stem sizes, two
metaphyseal parts, and three head
sizes in order to reconstruct the prox-
imal humerus as well as possible
F High percentage of tuberosity healing
achievable
F Optional combination with eccentric
heads of the Affinis total shoulder
prosthesis
F Optional combination with the
glenoid components of the Affinis
total shoulder prosthesis
F Good pain control even in the
absence of tuberosity healing and/or
intensive rehabilitation
Disadvantages
F Potential dislocation and resorption
of tuberosities in fracture prosthesis
F Limited long-term experience (al-
though extensive mid-term experience
with first generation design available)
F Long and intensive rehabilitation nec-
essary to obtain good functional result
Indications
Controversy remains about the indica-
tion for shoulder arthroplasty in acute
22 |  Operative Orthopädie und Traumatologie 1 · 2011
Operative Techniken
fractures. Therefore, we developed a new
scoring system. This scoring system has
been based upon the evaluation of 383
proximal humerus fractures treated by
angular stable fixation. Using this system
a score of 4 points has a positive predictive
value of 0.97 for failure and a negative pre-
dictive value of 0.92.
Thus, a strong indication for primary
arthroplasty is considered if at least four
points are scored:
F Avascular head fragment* (2 points)
F Friable patient** (1 point)
F Inability to obtain a stable, anatomical
fixation (2 point)
1 Due to too small head fragment
1 Due to inability to reconstruct the
tubercles anatomically
F Head split fractures (1 point)
F Combined complex proximal
humerus and glenoid fracture
­(necessitating surgical reconstruction
of the glenoid) (1 point)
*To judge vascularity, the system of
Hertel [2] was used.
**Friable patient = ASA 3 or more
The final decision whether to perform
an osteosynthesis or a primary arthro­
plasty is often made during surgery.
Contraindications
F Patient unable to undergo surgery
F Severe dementia or other reasons
making it impossible to cope with
normal rehabilitation (although even
in these cases good reduction in per-
sistent pain).
F Pre-existing infection of the shoulder
F Coexisting bacteremia
F Rotator cuff insufficiency
Patient information
F General surgical risks
F Limited movement or loss of strength
compared to the healthy joint
F Complex, protracted rehabilitation
and follow-up
F Limited durability of the prosthesis
F Loosening or dislocation of the
prosthesis
F Periprosthetic fracture
F Glenoid erosion
F Infection
F Necessity to revise to inversed pros-
thesis in case of failed treatment. Can
be performed leaving the stem in due
to the modularity of the system.
Preoperative work-up
F History of the patient and general
preoperative work-up
F AP, lateral and axial X-ray of the
shoulder
F Optional CT scan of the shoulder
(mandatory if glenoid exchange
considered).
Surgical instruments and implants
F Standard shoulder instruments
F No. 5 nonabsorbable sutures
F No. 2 nonabsorbable sutures
F No. 2 FiberWire sutures (Arthrex)
F 1 or 2.0 mm cable system (e.g., Dall
Miles (Howmedica), Cable ready
(Zimmer), Tubercable (Argomedical)
F Affinis Fracture instruments: 3 shaft
reamers, 3 trial heads, hexagonal
screw driver, torque-limiting key,
counter key, retroversion indicator
(left and right), and test screw
F Affinis Fracture prosthesis:
1 3 ceramic heads (diameters: 42, 45,
and 48 mm)
1 3 stem sizes (diameters: 6, 9, and
12 mm) in 125 and 200 mm lengths
1 2 metaphyseal sizes (small and
standard)
1 Optional eccentric Affinis CoCr
heads (diameter/height: 39/13, 41/14,
43/15, 45/16, 47/17, 49/18, 51/19,
53/20)
Anesthesia and positioning
F General anesthesia is preferred in
most cases, but in selected cases one
can use an interscalene block (with
sedation).
F The patient is operated upon in the
beach chair position. It is important
to have the arm freely movable,
especially to be able to retroflex and
to adduct the arm.
F Fluoroscopic imaging of the entire
shoulder should be warranted.
Abstract · Zusammenfassung

Orthop Traumatol 2011 · 23:21–28  DOI 10.1007/s00064-010-0012-8

© Springer-Verlag 2011

S. Nijs · F. Reuther · P. Broos

Primary fracture arthroplasty of the proximal humerus using a new and freely adjustable
modular prosthesis combined with compression osteosynthesis of the tuberosities
Abstract
Objective.  Prosthetic joint replacement in stem (3 sizes), a metaphyseal part (2 sizes), the first few days, passive mobilization, with-
case of non-reconstructable proximal hu- and a ceramic head (3 sizes). The retroversion in pain limits, is performed. As soon as pos-
merus fracture in order to obtain a pain-free of the metaphyseal part is freely adjustable sible, active assisted mobilization is started.
shoulder and an acceptable range of motion. (360°) after cementing the stem. The length No stretching is performed, especially in ro-
Indications.  The non-reconstructable prox- can be adjusted over 1 cm. After reconstruc- tation, before the sixth postoperative week.
imal humerus fracture in aged, frail patients tion of the height and retroversion, the tuber- The arm is supported in a sling, only for anal-
(over 70 years of age or ASA 3). osities are reattached anatomically. Finally, a gesic reasons.
Contraindications.  Patient inoperable or compression osteosynthesis of the tuberosi- Results.  Using this technique, anatomical
­rehabilitation is inacceptable, pre-existing in- ties is realized, using a metal cable, compress- healed tuberosities were obtained in 84% of
fection of the shoulder, coexisting bactere- ing the tuberosities directly upon the me- the 44 patients with a mean Constant score
mia, or rotator cuff insufficiency. taphyseal part. of 59 points.
Surgical technique.  Using a deltopectoral or Postoperative management.  As the stabil-
deltoid split approach, the head fragment is ity of this construct is very high, early post- Keywords
removed. After reaming of the humeral canal, operative mobilization is allowed. In order Proximal humerus · Shoulder · Fracture ·
a stem is cemented in place. The Affinis Frac- to avoid adhesion, rehabilitation exercis- Orthopedic procedures · Treatment
ture prosthesis consists of three parts: the es are started the day after surgery. During

Gelenkersatz nach primärer Fraktur des proximalen Humerus unter Verwendung

einer neuen und frei anpassbaren modularen Prothese in Kombination
mit einer (Kabel-)Kompressionsosteosynthese der Tubercula
Zusammenfassung
Operationsziel.  Prothetischer Gelenkersatz
bei nichtwiederherstellbaren proximalen Hu-
merusfrakturen mit dem Ziel einer schmerz-
freien Schulter und akzeptabler Bewegungs-
freiheit.
Indikationen.  Nichtrekonstruierbare proxi-
male Humerusfraktur bei vorwiegend älteren
Patienten (ab 70 Jahre oder ASA 3).
Kontraindikationen.  Patient inoperabel
bzw. Rehabilitation unzumutbar, vorbeste-
hender Schulterinfekt, gleichzeitige Bakteriä-
mie sowie Insuffizienz der Rotatorenman-
schette.
Operationstechnik.  Über einen deltopekt­
oralen oder „Delta-split“-Zugang wird das
Kopffragment entfernt. Danach wird der Hu-
meruskanal ausgefräst und der Prothesen-
schaft einzementiert. Die verwendete Af-
finis-Frakturprothese (Mathys AG Bettlach,
Schweiz) besteht aus drei Teilen: Schaft
(3 Größen verfügbar), Mittelteil (2 Größen)
und Keramikkopf (3 Größen). Nach dem
Einzementieren des Schafts kann die Retro-
version des Mittelteils frei eingestellt werden
(360°). Die Länge lässt sich um mehr als 1 cm
anpassen. Nach der Rekonstruktion der Höhe
und der Retroversion werden die Tubercu-
la anatomisch refixiert. Schließlich erfolgt mit
einem Metallkabel eine Kompressionsosteo-
synthese der Tubercula, indem diese direkt
an das (beschichtete) Mittelteil angepresst
warden.
Weiterbehandlung.  Konnte eine stabile Tu-
berkelfixation erreicht werden, ist die unmit-
telbare passive Mobilisierung innerhalb der
Schmerzgrenzen erlaubt. Mit aktiv unterstüt-
zter Mobilisierung wird bereits nach einigen
Tagen begonnen. Vor der 6. post­operativen
Woche sollte keine Dehnung, besonders in
Rotation, erfolgen. Aus analge­tischen Grün-
den wird empfohlen, den Arm in einer
­Schlinge zu tragen.
Ergebnisse.  Mit dieser Technik verheilten bei
84% der 44 Patienten die Tubercula in anato-
mischer Position. Der mittlere Constant-Score
betrug 59 Punkte.
Schlüsselwörter
Proximaler Humerus  · Schulter · Fraktur ·
Orthopädische Verfahren · Behandlung

Operative Orthopädie und Traumatologie 1 · 2011  | 23

 Operative Techniken

Surgical technique M. pectoralis maj.

Proc. coracoideus
The surgical technique is illustrated in Acromion
. Fig. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and
Fig. 12. M. deltoideus

Fig. 1 8 In most cases, a standard deltopectoral approach is used, especially when the decision to
­perform an open reduction and internal fixation or an arthroplasty is made intraoperatively. If the de-
cision to treat the fracture by arthroplasty is made preoperatively, the delta split approach can be used
as an alternative. This allows for better visualization and control of the greater tuberosity fragment.
Using the delta split approach, meticulous care must be taken to avoid damage to the axillary nerve
and to reconstruct the delta insertion on the acromion when ending the procedure. The coracoacro-
mial ligament should also be preserved during surgery

Reamer

Acromion
M. supraspinatus
Proc. coracoideus
M. subscapularies

Fig. 3 9 Reaming of the

humeral shaft using in-
creasing reamer diame-
ters: 6–9–12 mm. Stop
reaming as soon as ade-
Temporary Temporary quate cortical contact is
suture suture
achieved
Temporary
Tuberculum maj. suture
Tuberculum min.

Fig. 2 8 Manipulation sutures are placed on the greater and lesser tuberosi-
ties. They are placed at the transition of the tendon’s insertion to the bone, as in
many cases the bone is too weak to allow for adequate manipulation without
causing additional damage. The interval between the two fragments is opened
to retrieve the humeral head. Often this will lie lateral to the groove of the bi­ci­
pital­tendon and, thus, lateral to the rotator cuff interval. If necessary, the con- Fig. 4 9 Four drill holes
tinuation of the fracture line into the rotator cuff is further split to obtain ade- are made in the humeral­
quate exposure. When performing this split, it is important to remain strictly in shaft; two anterior and
line with the vessels of the supraspinatus tendon. After adequate mobilization two posterior–later-
of the tuberosities, the head is removed, preferably as one piece. If some carti- al. These are armed with
laginous remnants are connected to the tuberosities, these need to be removed. two No. 5 nonabsorbable
The long head of the biceps tendon is released from its insertion sutures

24 |  Operative Orthopädie und Traumatologie 1 · 2011


Fig. 5 8 The definitive stem and metaphyse-
al part are assembled, whereby the metaphyse-
al part is mounted in a middle position. Normally,
we implant a standard metaphyseal part. In case
of a small head combined with relatively volumi-
nous tuberosity fragments, the small metaphyse-
al part can be chosen. One can fix the metaphyseal
part on the stem using the expansion mechanism
of the stem (central expansion screw) which will
be expanded fully once the definitive position of
the metaphyseal part has been realized, or using
a separate test screw. If the expansion mechanism
is used, fix it only hand-tight to make this easily
­reversible in order to correct version and height. If
the test screw is used, ensure it does not impede
the exact (deep) implantation of the prosthesis.
Under no circumstance should additional bone be
resected in order to create space for the test screw
Fig. 6 8 After introduction of a cement blocker in-
to the shaft and a thorough lavage (preferentially
jet lavage), the shaft is cemented using a cement
pressurizing technique. The stem is introduced as
deep as possible. Only in cases with extensive me-
taphyseal comminution should reconstruction of
the length be considered during this phase. Again,
it must be stressed that the test screw should not
limit deep insertion of the stem. Retroversion­
is not of any importance now. Excess cement is
­removed from the superior part of the shaft. In
case of a wide superior part of the shaft, bone
grafts from the head can be used to centralize the
stem. In all cases, a layer of bone grafts is laid upon
the cement in the most proximal part of the shaft
Fig. 7 8 After the seating of the cement, the
retroversion of the humeral head is correc­ted.
Loosening the connection screw or the test
screw, the retroversion can be adjusted with-
out limit. We aim for a retroversion of about 25–
30° relative to the forearm (i.e., the anatomical
re­troversion of the humeral head relative to the
axis of the forearm). In case of pre-existing post­
erior dislocation of the head fragment, 25° of
retroversion is advocated. If the blocking screw
is in line with the forearm, 30° retroversion is
achieved. A retroversion indicator (left and
right) can be placed in the superior hole of the
metaphyseal part. If this is in line with the fore-
arm, 30° retroversion is also achieved. When the
arm is in a neutral rotation, the humeral head
should face the glenoid

Acromion

Tuberculum maj.
Tuberculum min.

Proc. coracoideus

a b

Fig. 8 8 Choose the trial head, based on comparison to the size of the removed head fragment. In case of
doubt or when the size of the removed head is situated between two head sizes, the smaller head should
be chosen to avoid overstuffing the joint (a). Reconstruction of the humeral length is very important. Posi-
tioning of the prosthesis too high should be avoided at all costs. The easiest method of height adjustment is
to measure the metaphyseal extension of the calcar = ‘d’. The most inferior part of the humeral head should
be ‘d’ above the corresponding part of the calcar remnants on the shaft. Note that the average length of the
humeral calcar in Caucasians is 8 mm. If the medial metaphysis is comminuted too much, the greater
tuberosity can be repositioned laterally. The highest point of the humeral head should than be 8 (5–10) mm
above the greater tuberosity’s highest point (head tubercle distance) ([4], b)

Operative Orthopädie und Traumatologie 1 · 2011  | 25

 Operative Techniken

Fig. 11 8 If both height and retroversion are

­reconstructed satisfactorily, the central screw is
hand-tightened (if a test screw was used for pre-
liminary fixation). The tuberosities are repositioned
preliminarily around the prosthesis, and both visu-
ally and under fluoroscopy it is checked to deter-
mine whether anatomical reconstruction has been
obtained. If the positioning is not satisfactory, both
Fig. 9 8 When taking these measurements into account, the Gothic arch [3] should be restored. This is height (1 cm correction possible) and retrover-
a continuous line following the medial side of the humeral shaft, the humeral calcar, the glenoid neck, sion can be corrected as needed. If the positioning
and the lateral side of the scapula is satisfactory, the trial head is removed. The cen-
tral screw is tightened definitively using the torque
wrench and the counter key. The definitive head is
now positioned and fixed by using a pushing and
Acromion
slightly turning motion. It is normal to see on an
­X-ray control a narrow radiolucent line between
M. supraspinatus the head and the cone
Tuberculum maj.

Proc. coracoideus

M. subscapularies

Tuberculum min.

Fig. 10 8 If there is extreme comminution of the medial and lateral metaphysis,
both the calcar and the anatomical repositioning of the greater tuberosity can
become impossible to use. In such a case, the pectoralis major tendon distance
can be used. In a cadaveric study of 20 specimens, Warner et al. [5] demonstra­
ted that the distance between the highest point of the humeral head and the
proximal border of the pectoralis major tendon is 5.6±0.5 cm

26 |  Operative Orthopädie und Traumatologie 1 · 2011


Fig. 12 8 A No. 2 FiberWire suture (red) is
passed through the proximal metaphyseal hole.
A 1 or 2 mm metal cable (steel or titanium)
(grey) is passed through the central metaphyse-
al hole. Then the cable is brought through the
infraspinatus tendon posteriorly and the sub-
scapularis anteriorly. If the manipulation su-
tures are suboptimally positioned, they are ex-
changed, so that both tuberosities are armed
with a single No. 5 nonabsorbable suture at
the tendon bone interface (green). The shaft al-
ready was armed anterior– and posterior–later-
al by a No. 5 nonabsorbable suture (blue). First,
the red suture is passed through the supraspi-
natus tendon at its footprint. Tying this suture
fixes the footprint at its anatomical position.
Then both tuberosities are repositioned and
fixed against each other using the green sutures.
Next, the blue sutures are brought through the
rotator cuff in order to fix the tuberosities on the
shaft. A final fluoroscopic control confirms the
anatomical reconstruction. Then the steel ca-
ble is tensioned to fix the tuberosities stable up-
on the metaphyseal part by compression. This
step needs to be performed meticulously to ob-
tain adequate compression, while avoiding cut-
ting or squeezing of the tuberosities. Therefore,
the stability and amount of compression should
be checked frequently. A tenodesis of the long
head of the biceps tendon is performed in the
groove, and the split in the rotator cuff is closed
using No. 2 nonabsorbable sutures
Postoperative management
F The arm is supported in a sling, only
for analgesic reasons.
F Early postoperative mobilization.
During the first days, passive mobili-
zation is preferred, within pain limits.
Active assisted mobilization is started
from the first postoperative day. No
stretching is performed, especially in
rotation, before the sixth postopera-
tive week.
Errors, hazards, complications
F The too-high implantation of the
prosthesis, nonunion of the tuberosi-
ties, rotator cuff insufficiency and an-
teriosuperior dislocation of the pros-
thesis: revert to a reversed-type shoul-
der prosthesis.
One has to resolve this problem intra­
operatively. First, the metaphyseal part has
to be mounted on the stem in a middle
position. Test screw does block the inser-
tion of the stem: it has to be removed, and
the metaphyseal part has to be secured
on the stem using the central expansion
screw. Height has to be restored using the
above-mentioned techniques:
1 Reconstruction of the calcar length
1 Reconstruction of the head–
tubercle distance
1 Reconstruction of the Gothic arch
1 Reconstruction of the pectoralis
major tendon distance
F No shaft–tuberosity contact: lower
the metaphyseal part
F Early dislocation of the prosthesis in
case of an obvious failure in retro­
version: disassemble the tuberosity­
­reconstruction, loosen the central
locking screw, restore adequate retro­
version, and reattach the tuberosities.
Risk of nonunion of the tuber­osities
substantially increases if secondary­
surgery is necessary. Glenoid rim
fractures: a glenoid component has
to be used (perhaps after augmenting
the glenoid by a bone block).
F Early displacement of the tuberosi-
ties: if the fragment can be localized
on the CT scan, the tuberosities can
be reattached. Again, the risk of non-
union of the tuberosities is substan-
tially increased.
F Nonunion of the tuberosities: loss of
function is too severe; one can con-
sider conversion to a reversed shoul-
der prosthesis. Given the system this
can be done with the stem in situ,
­exchanging the head and metaphyseal­
part and implanting a reversed gle-
noidal component. One has to real-
ize that the result after revision to re-
versed shoulder arthroplasty is poor-
er than after primary reversed arthro-
plasty.
Operative Orthopädie und Traumatologie 1 · 2011  | 27
F Anteriosuperior dislocation: result of
rotator cuff insufficiency combined
with failing superior restraints
(coracoacromial ligament): repair
using a reversed shoulder prosthesis.
F Infection. If early: repeated lavage and
debridement combined with antibi-
otic therapy can solve the problem. If
persistent or late presentation:
hardware removal becomes necessary.
F Glenoid erosion. If symptomatic,
a glenoid component has to be
inserted.
F Periprosthetic fractures: nonopera-
tive treatment in case of stable fixa-
tion and minimal displacement. If the
displacement is more severe, angular
stable plate and screw osteosynthe-
sis combining monocortical screws
and a cable system allows for stable
refixation. In case of fracture around
a loose prosthesis, revision to a long
stem prosthesis becomes necessary.
Results
Between June 2006 and December
2007, 50 patients (51 fractures) were
treated­ for acute fracture using the Affi-
nis fracture prosthesis. In 1 patient with
an isolated anatomical neck fracture,­
an ­excentric head was used and no
­tuberosity osteosynthesis was necessary.­
This ­patient has been excluded from
the study. This leaves 50 prostheses in
44 women and 5 men. The mean age of
these 50 patients was 74.2 years (range
46–91 years).
Fourteen patients have been lost for clin-
ical follow-up. One male patient devel-
oped a deep infection, necessitating a
2-stage revision to reversed prosthesis.
Six patients (including the 1 with bilater-
al prostheses) died within the observa-
tion period of fracture-unrelated causes.
Five patients were in such poor general­
condition that further clinical follow-up­ 
was impossible. In none of these patients­
was secondary surgery performed.
One psychiatric patient was completely­
lost for follow-up. For 8 of these 14 pa-
tients, we have at least 6 months of ra-
diographic follow-up. Thus, 36 (4 men,
32 women) patients with both clinical
and ­radiographic follow-ups and 44 with
a 6-month radiographic follow-up were

available. The mean age of this group  
was 73 years (range 47–87 years).
The mean Constant score was 59 points
(range 31–89). The mean forward range  
of motion was as follows: elevation
97.6°, abduction 92.1, exorotation 6.4/10  
points and endorotation 6.8 points. The
mean pain score was 12.3 points.
The tuberosities healed anatomically in
37 of 44 patients (i.e., 84%), and in 38 of  
44 (i.e., 86%) patients the head remained
centered on the glenoid. Given the   with hemiarthroplasty for fracture. J Shoulder El-
relatively high number of patients lost
 
for follow-up rates, we also considered
the worse case analysis (i.e., each   (5):34–35
patient who is lost was considered as  
having a nonunion and a decentraliza-
tion). In this analysis, the healing rate
was 74% and the head remain central-  
ized in 76% of patients. All the nonana-
tomical healings (6 patients) occurred in
female patients. In 2 patients, a   73(2):179–187
primary malposition was observed on
the postoperative X-ray. The 4 other   Das Programm im Überblick:
patients were over 79 years of age, dem-
onstrating the failing biological potential
of healing in this group of patients.
There was a significant difference in out-
come between male and female pa-
tients. The mean Constant score in men
was 85.5 points, while it was 55 points
in females (p<0.001 but the male group
of course is very small and significant-
ly younger). We cannot demonstrate a
strong relation between increasing age
and lower scores (r=−0.280), although
there was a trend towards lower scores in
the aged.
Corresponding address
Prof. Dr. S. Nijs
Department of Traumatology, UZ Leuven
Herestraat 49, 3000 Leuven
Belgium
stefaan.nijs@uzleuven.be
Conflict of interest.  S. Nijs and F. Reuther are medical
advisors for Mathys Bettlach and are financially reim-
bursed for their advisory activities.
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