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J Bone Joint Surg Am. 2013 Nov 20;95(22):2050-5. doi: 10.2106/JBJS.L.01637.
Treatment of complex three and four-part proximal humeral fractures with hemiarthroplasty in elderly patients has yielded mixed clinical results. Reverse shoulder arthroplasty has emerged as a treatment option for comminuted proximal humeral fractures for these patients. The purpose of the study was to perform a prospective evaluation of patient outcomes comparing hemiarthroplasty and reverse shoulder arthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients.
Fifty-three consecutive elderly patients (average age, 74.4 years) underwent an arthroplasty for a complex proximal humeral fracture. Indications for arthroplasty were four-part fractures, three-part fractures with severe comminution of the greater tuberosity, and fractures that involved an articular split of the humeral head. Twenty-six patients underwent hemiarthroplasty (the HA group), followed by twenty-seven patients who underwent reverse shoulder arthroplasty (the RSA group). A total of forty-seven patients (twenty-three in the HA group and twenty-four in the RSA group) were available for follow-up at a minimum of two years.
Final average outcome scores were lower in the HA group than in the RSA group (American Shoulder and Elbow Surgeons [ASES] score of 62 versus 77 [p = 0.0001] and Simple Shoulder Test [SST] of 5.8 versus 7.4 [p = 0.0062]), and patient-reported satisfaction was lower in the HA group than in the RSA group (61% versus 91%; p = 0.038). Radiographic healing of the tuberosities occurred in 61% of the patients in the HA group compared with 83% of the patients in the RSA group (p = 0.17). Forward elevation of the arm was higher in the RSA group (139°) than in the HA group (100°) (p = 0.0002), but no significant differences were observed for shoulder external rotation or internal rotation. Complication rates in both groups were similar. Three patients (13%) in the HA group elected revision to reverse shoulder arthroplasty because of failed tuberosity healing and resultant shoulder pseudoparesis.
In this series, reverse shoulder arthroplasty resulted in better clinical outcomes and a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the elderly.
对于老年患者复杂的三部分和四部分肱骨近端骨折，采用人工半肩关节置换术的治疗效果参差不齐。对于这些患者的粉碎性肱骨近端骨折，反式肩关节置换术已成为一种治疗选择。本研究的目的是前瞻性评估人工半肩关节置换术和反式肩关节置换术治疗老年患者粉碎性肱骨近端骨折的患者结局。
53 例连续的老年患者（平均年龄 74.4 岁）因复杂的肱骨近端骨折接受了关节置换术。关节置换术的适应证为四部分骨折、三部分骨折伴大结节严重粉碎性骨折以及涉及肱骨头关节面劈裂的骨折。26 例患者接受了人工半肩关节置换术（HA 组），随后 27 例患者接受了反式肩关节置换术（RSA 组）。共有 47 例患者（HA 组 23 例，RSA 组 24 例）在至少 2 年的时间里接受了随访。
HA 组的最终平均结局评分低于 RSA 组（美国肩肘外科医生协会评分 62 分对 77 分，p = 0.0001；简易肩部测试评分 5.8 分对 7.4 分，p = 0.0062），且 HA 组患者的报告满意度低于 RSA 组（61%对 91%，p = 0.038）。HA 组有 61%的患者出现大结节愈合，而 RSA 组有 83%的患者出现大结节愈合（p = 0.17）。RSA 组的手臂前屈上举角度更高（139°），而 HA 组的前屈上举角度更低（100°）（p = 0.0002），但两组间的肩部外旋和内旋无显著差异。两组的并发症发生率相似。HA 组有 3 例患者（13%）因大结节愈合失败和由此导致的肩部假性瘫痪而选择翻修为反式肩关节置换术。
在本系列中，与人工半肩关节置换术相比，反式肩关节置换术治疗老年粉碎性肱骨近端骨折的临床效果更好，并发症发生率相似。
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