Retrospective single-center series of 173 patients over age 60 treated with locking plate ORIF for proximal humerus fractures from 2005 to 2015. Asks whether modern principle-based technique — liberal fibular allograft use, valgus reduction, calcar support — has reduced historically high failure rates in this population. Average follow-up was 6.1 years.
A 73-year-old woman with a displaced 3-part proximal humerus fracture sits across from you in clinic. The question is not whether you can fix it — you almost certainly can, with valgus reduction and calcar support 95-98% of the time. The question is whether fixation will hold.
This paper makes the answer uncomfortable: even at a high-volume center after the learning curve, 39% of 3-part and 45% of 4-part fractures fail in patients over 60. Most failures are biological. Progressive AVN that unfolds months after the plate has done its job. No amount of technique refinement prevents a head with compromised vascularity from collapsing.
When you see a displaced 3- or 4-part fracture in a patient in their 70s or 80s, these data support a direct conversation about primary rTSA. The authors' own practice shifted in that direction, citing an approximately 5% failure rate for rTSA in this setting versus 39-45% for ORIF.
Do not let a low reoperation rate (11%) reassure you. Most failures in this series went unrevised because patients refused further surgery, not because they recovered.
Retrospective single-center series of 173 patients over age 60 treated with locking plate ORIF for proximal humerus fractures from 2005 to 2015. Asks whether modern principle-based technique — liberal fibular allograft use, valgus reduction, calcar support — has reduced historically high failure rates in this population. Average follow-up was 6.1 years.
A 73-year-old woman with a displaced 3-part proximal humerus fracture sits across from you in clinic. The question is not whether you can fix it — you almost certainly can, with valgus reduction and calcar support 95-98% of the time. The question is whether fixation will hold.
This paper makes the answer uncomfortable: even at a high-volume center after the learning curve, 39% of 3-part and 45% of 4-part fractures fail in patients over 60. Most failures are biological. Progressive AVN that unfolds months after the plate has done its job. No amount of technique refinement prevents a head with compromised vascularity from collapsing.
When you see a displaced 3- or 4-part fracture in a patient in their 70s or 80s, these data support a direct conversation about primary rTSA. The authors' own practice shifted in that direction, citing an approximately 5% failure rate for rTSA in this setting versus 39-45% for ORIF.
Do not let a low reoperation rate (11%) reassure you. Most failures in this series went unrevised because patients refused further surgery, not because they recovered.