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Nerve injury is the most feared complication of upper limb surgery. In about 17% of cases, the injury is iatrogenic and the potential for recovery is poor. In this context, patients file for compensation in about a quarter of cases. Defective patient installation or locoregional anaesthesia are rarely the cause of nerve injury. Nerves may be injured during creation of the surgical approach, implantation of the material or reduction of a traumatic injury. The injury is usually related to nerve release, retractor positioning or inappropriate limb-segment lengthening. Stretching and/or compression of a nerve trunk or branch is thus often the main cause. Among diagnostic tools, imaging studies (ultrasonography, computed tomography, and magnetic resonance imaging) provide information on nerve structure but not on the potential for recovery. Electromyography combined with a neurological examination establishes the diagnosis, guides the management strategy, allows nerve-function monitoring, and indicates when nerve repair or palliative surgery is indicated. Electromyography also has prognostic value, both at diagnosis and during follow-up, by showing whether nerve regeneration is taking place. When creating the surgical approaches, thorough familiarity with anatomic safe zones and nerve trajectories is crucial to ensure full control of the zones at highest risk for nerve injury. LEVEL OF EVIDENCE: IV., (Copyright © 2024. Published by Elsevier Masson SAS.)

Background: Surgery and non-operative treatment produce similar 1-year functional outcomes in patients older than 65 years. Data are lacking for patients older than 75 years. The main objective of this study was to compare surgical vs. non-operative treatment regarding short-term outcomes in patients older than 75 years. In addition to an overall analysis, sub-group analyses were done in patients with displacement and severe displacement (>20 ° posterior tilt)., Hypothesis: Surgery provides better clinical and radiological outcomes than does non-operative treatment., Patients and Methods: Patients older than 75 years at the time of a distal radius fracture were included prospectively over a 2-year period. A follow-up duration of at least 6 months was required. Treatment choices were based on displacement, Charlson's Co-morbidity Index, and patient autonomy. Surgery consisted in open fixation using an anterior locking plate and non-operative treatment in a short arm cast without reduction. The main assessment was based on clinical criteria: range of motion, strength, visual analogue scale (VAS) scores, the short version of the Disabilities of the Arm, Shoulder, and Hand tool (QuickDASH), the Patient Rated Wrist Evaluation (PRWE), and the 36-Item Short Form Health Survey (SF-36). The secondary assessment criteria were the radiological outcomes and the complications., Results: 74 patients were included, among whom 24 were treated surgically and 50 non-operatively. At 1.5 months, surgery was associated with significantly better results for flexion, ulnar inclination, and supination, with range increases of at least 7 ° vs. non-operative treatment, and with greater dorsal angle and ulnar variance values (p < 0.05 for all comparisons). At 6 months, pronation and the radio-ulnar index were better with surgery (p < 0.05 for both comparisons). In the patients with displacement or severe displacement, surgery was associated with 10° gains vs. conservative treatment for flexion, ulnar inclination, and supination at 1.5 months (p < 0.05 for all comparisons)., Discussion: In patients older than 75 years, surgery for distal radius fracture was associated with significantly better clinical and radiological outcomes within 6 months. Surgery is recommended for displaced and severely displaced distal radius fractures to expedite the recovery of joint motion ranges. Beyond 6 months, the outcomes are similar., Level of Evidence: III., (Copyright © 2024. Published by Elsevier Masson SAS.)

Introduction: A fracture classification system should provide a reliable and reproducible means of communication between different parties. It should be logical and understandable, with few categories to memorize. The aim of this study was to determine the intra- and interobserver reliability of the Schatzker and Mayo classification systems for the assessment of proximal ulna fractures., Materials and Methods: Intra- and interobserver reliability studies were conducted on 39 X-rays of injured elbows drawn randomly from 74 cases previously used in a series on predictors of ulnohumeral osteoarthritis in proximal ulna fractures. Ten observers independently reviewed these X-rays on 2 separate occasions 3 months apart. The fracture type was assessed according to the Schatzker and Mayo classification systems during each reading session. Cohen's and Fleiss' kappa were used to measure the intra- and interobserver reliability., Results: The Schatzker classification had a fair interobserver reliability for the first (Schatzker R 1 , Fleiss' κ: 0.394) and second (Schatzker R 2 , Fleiss' κ: 0.351) readings. The mean intraobserver reliability value between the 10 reviewers for the Schatzker classification was rated as substantial (0.61). The Mayo classification had a fair interobserver reliability for the first (Mayo R 1 , Fleiss' κ: 0.278) and second (Mayo R 2 , Fleiss' κ: 0.292) readings. The mean intraobserver reliability value between the 10 reviewers for the Mayo classification was rated as fair (0.52)., Discussion: The classification systems for proximal ulna fractures showed poor reproducibility between the different observers since they had low interobserver agreement values. Nevertheless, their use remained reliable since the measured intraobserver agreement value was deemed substantial., Level of Evidence: IV; retrospective., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Introduction: Despite optimal arterial anastomosis, some finger replantations fail. Our objective was to evaluate how the mechanism of injury (MOI) affects the artery's microscopic appearance and the success of anastomosis. We hypothesized that the MOI influences arterial histology and microsurgical success., Methods: This single-center prospective study enrolled patients who had an acute traumatic arterial injury of the hand and/or wrist. The proximal and distal ends of the artery were trimmed before anastomosis in every case. The arterial margins were analyzed in anatomical pathology. Clinical follow-up along with an ultrasound arterial patency check was carried out at 1 month postoperative., Results: Between 2018 and 2022, 104 patients were enrolled with a follow-up of 12 months. Macroscopically, 42% of the arterial margins were dilapidated. Histological analysis found damage in 74% of surgical specimens: blast (100%)>laceration by mechanical or power tool (92%; 82%)>amputation by mechanical or power tool (80%; 67%)>laceration by glass (50%)>crush injury (33%). The arterial margins were more likely to be normal based on the histological analysis when the MOI was laceration by glass (p<.05; OR=3.72) and the patient was 65 years or older (p<.01). Risk factors for anastomosis failure were an amputation by power tool (p<.01, OR 8.19) and shorter length of arterial resection (p<.02). The clinical failure rate was 7.8% and the patency failure rate was 10.4%., Discussion: Histological arterial lesions correlate with the MOI. Trimming >2mm from the proximal and distal arterial ends is recommended for all MOI before arterial end-to-end anastomosis. For blast injuries or amputation, we recommend trimming>4mm and using a vein bypass graft. This study's findings could lead to a change in surgical practices., Level of Evidence: II; well-conducted non-randomized comparative study; recommendation grade B: scientific presumption., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Introduction: Acromioclavicular (AC) joint separation is a common shoulder injury. When the injury is graded as type III or higher in the Rockwood classification, surgical treatment can be proposed. However, an increasing number of practitioners are shifting back to conservative treatment as it is associated with fewer complications and seemingly close functional outcomes. The aim of our study was to evaluate the functional recovery of operated and non-operated patients with grade III or higher AC joint injuries. Secondarily, the reliability and relevance of the Rockwood classification was evaluated within and between raters., Materials and Methods: We did a retrospective two-center study of 38 patients treated between 2014 and 2020. The clinical evaluation involved various functional outcome scores (Constant, QuickDASH, ASES, UCLA, SSV, STT) and a pain assessment (VAS). Return to sports and to work was also documented. The radiological evaluation consisted of Zanca AP and lateral axillary views immediately after the injury and at each radiographic follow-up visit until the final visit. An intra- and inter-rater analysis was also done for the Rockwood classification., Results: There was no significant difference in the functional scores (Constant score surgery group=91, nonoperative group=83; p=0.09) or the pain on VAS at the final assessment. Return to work and to sports was significantly faster in patients treated non-operatively. No complication was found in the non-operated patients, while nine of the operated patients suffered a complication. The inter-rater reliability of the Rockwood classification was found to be poor (kappa=0.08) to fair (kappa=0.35), while the intra-rater reliability was moderate (kappa=0.6) to good (kappa=0.63)., Discussion/conclusion: No matter which treatment is used, the functional outcomes and patient satisfaction level a minimum of 1 year after the injury appear to be identical. Thus, surgery should be only for patients whose AC joint is painful 7 days after the injury (VAS>7) and whose function has not improved. For young and athletic patients or for patients who simply want to regain nearly normal function, it is important to remember that the time to return to work and sports is longer with surgical management and to take into consideration the potential postoperative complications. While none of the patients who received the non-operative treatment required a secondary stabilizing surgery, this is a possible recourse., Level of Evidence: III., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: In 2020, the pandemic divided France into two zones: COVID-19 and non-COVID-19. The main objective of our study was to compare the variability of surgical and emergency consultation activity amongst two hand trauma centers, between the pandemic period and outside the pandemic period. The secondary objective was to identify at-risk patients in order to develop preventative strategies in hand trauma., Methods: This bi-centric retrospective study considered the epidemiology of admissions to trauma centers during the first French lockdown. The data were compared to the same period in 2019 (control group). Two thousand and fifty-five patients underwent consultations for hand or wrist trauma., Results: The first French lockdown was associated with a 35% decrease in hand and wrist injuries in the COVID-19 zone versus 24% in the non-COVID-19 zone, compared to the same period in 2019 (p<0.0001, 95% CI: 6.5-15.6). Comparing 2019 and 2020, the incidence of wounds significantly increased in the COVID-19 zone (58% vs. 78%, p<0.0001) and significantly decreased in the non-COVID-19 zone (55% vs. 50%, p<0.0001). Complex wounds (16% vs. 35%, p<0.0001 and 15% vs. 17%, p<0.0001) and open fractures (8% vs. 14%, p=0.019 and 4.5% vs. 5.3%, p<0.0001) significantly increased in both zones during the pandemic. The rate of male, non-manual workers injured in domestic accidents (76% vs. 36%, p<0.0001) was significantly increased in all areas., Conclusion: Hand and wrist trauma was less frequent but more severe during the pandemic compared to the same period in 2019. By encouraging the public to be aware of the risks and the means to avoid trauma, such as better information and compliance with safety instructions, we could minimize these risks. This data can be useful in planning preventative strategies for future lockdowns., Level of Evidence: III; case-control study., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Introduction: In France, a national lockdown related to the COVID-19 pandemic was imposed from March 17 to May 11, 2020, drastically changing our professional and organizational practices. We were interested on the impact of the lockdown on fragility fractures in older adults (65 years and older). The primary objective of this study was to evaluate the incidence of peripheral and pelvic fragility fractures during the lockdown. The secondary objectives were to carry out an epidemiological analysis of the fractures, treatments and hospitalization data., Hypothesis: The main hypothesis was that the number of peripheral and pelvic fragility fractures was lower during the lockdown in 2020 than in the same (non-lockdown) period in 2019., Materials and Methods: We retrospectively collected epidemiological (age, sex), clinical (type of fracture, treatment) and hospitalization data from patients 65 years and older who came to the emergency room because of a peripheral and/or pelvic fracture between March 17 and May 11 of the years 2019 and 2020., Results: We included 192 patients in 2019 and 157 patients in 2020. The mean age and sex ratio were not statistically different. The number of peripheral and/or pelvic fragility fractures decreased by 16%. The share of patients treated surgically was similar in both years (46% in 2019; 51% in 2020 (p=0.47)). The number of proximal femur fractures dropped by 21%. The mean time to surgery for these fractures was shorter in 2020 (p=0.02) although the mean length of hospital stay was unchanged (p=0.72) The mortality rate of patients hospitalized for fragility fractures did not increase significantly (p=0.51)., Discussion: We observed a reduction in the number of peripheral and pelvic fragility fractures in patients 65 years and older during the lockdown. To ensure that we met our goals of optimal care for proximal femur fractures, a general reorganization of the operating room was necessary. The continued availability of fully functional technical facilities despite this health crisis was crucial to being able to treat these fractures and to prevent increased mortality., Level of Evidence: III, case-control study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: The functional results of stemless reverse shoulder prostheses are similar to those with stems. However, the operative time and the bleeding appear less significant because of the absence of humeral reaming. To date, the data amongst the literature regarding this subject is limited. Thus, we report a retrospective evaluation on these 2 types of prostheses by assessing their respective intraoperative blood loss., Hypothesis: Reverse shoulder arthroplasty without a stem leads to less blood loss, compared to arthroplasty with a stem., Materials and Methods: Twenty-three patients underwent an operation for a stemless prosthesis, while 37 patients had a prosthesis with a stem. The hemoglobin was measured preoperatively, as well as postoperatively. Drainage of the operative site was maintained for two to three days. In the stem group, the preoperative hemoglobin was 14g/dL (11.7-16.6), while it was 13.1g/dL (11-15.8) in the stemless group., Results: The intraoperative bleeding reached 223cm 3 (80-530), with an operative duration of 81minutes (40-110) in the stemless group, compared to 260cm 3 (50-1000) and 92minutes (33-110) in the stem group. On the first day postoperatively, 333cm 3 (20-570) of blood had been collected by drainage for the stemless group, compared to 279cm 3 (40-550) in the stem group. The amount decreased the second day, with 139cm 3 (20-510) and 129cm 3 (0-750) respectively. There was no difference between the two groups regarding the postoperative hemoglobin level (11g/dL)., Discussion: There is no significant difference concerning the blood loss between reverse shoulder replacements with and without stems., Level of Evidence: III Retrospective case control study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: Traumatic injuries to the distal quarter of the leg present a significant risk of skin necrosis and exposure of the underlying fracture site or the osteosynthesis material that often result in bone and joint infection. In the case of small or medium-sized bone exposure, local muscles may be one of the best options for lower extremity coverage. We describe our experience using the extensor digitorum brevis muscle flap in a context of posttraumatic bone and joint infection in fourteen patients. Our main objective was to assess the outcomes and the donor-site morbidity of the extensor digitorum brevis muscle flap., Materials and Methods: A single-center retrospective study in a French reference center for bone and joint infection from 2014 to 2018 reviewed cases of traumatic injuries with skin complications and bone and joint infection that required an extensor digitorum brevis muscle flap coverage. Fourteen patients were evaluated for early and late complications, 11 men and three women with a mean age of 51.4±17.72 (19-71) years. Seven of these were open fractures and nine cases were pilon fractures. Donor-site morbidity was assessed in nine patients., Results: Early flap complications included two cases (14.2%) of hematoma, one case (7.1%) of partial necrosis and four cases (28.5%) of donor-site dehiscence. Late complications caused by persistent infection were found in two patients (14.2%), with one case (7.1%) of chronic osteoarthritis and one case (7.1%) of septic pseudarthrosis. From a functional and cosmetic point of view, eight patients (89%) were satisfied, to very satisfied., Conclusion: Experience and a multidisciplinary approach are keys in providing an optimal treatment strategy for complex cases of bone and joint infection. The extensor digitorum brevis muscle is a reliable flap for small defects with underlying infection. Being made up of muscle tissue, this flap offers good resistance to infection and enables satisfactory distribution of antibiotics., Level of Evidence: IV., (Copyright © 2021. Published by Elsevier Masson SAS.)

Introduction: Several studies have analyzed the functional recovery after plate fixation of a displaced fracture of the middle third of the clavicle beyond the 6th week. The aim of this study was to assess the early functional recovery in the first 6 weeks, which has not yet been investigated., Hypothesis: Functional recovery in the first 6 weeks after surgical treatment is better than in the first 6 weeks of functional (non-operative) treatment., Methods: Any patient who had a closed displaced fracture of the middle third of the clavicle - Edinburgh types 2B1 or 2B2 - was informed of the treatment options within a week of their fracture: surgical fixation by anatomic plate or functional treatment. A QuickDASH score was filled out weekly for 6 weeks and at 3 and 6 months. Similarly, the Constant score was determined at 3 and 6 weeks and at 3 and 6 months. Any complications were documented and time to union was determined., Results: Sixty-five fractures in 65 patients were followed for 6 months. Twenty-six patients chose surgical treatment (S) and 39 chose functional treatment (F). The Constant and QuickDASH scores were significantly better in the S group from the 2nd to the 6th week. At 3 weeks, we found a Constant score of 57.7 in group F versus 74.9 in group S (p<0.01) and a QuickDASH of 55.9 in group F versus 27.4 in group S (p<0.001). At 6 weeks, the Constant score was 71.3 versus 86.1 (p<0.001) and the QuickDASH was 28.3 versus 10.6 (p<0.01), respectively. At 3 and 6 months, the recovery was comparable in both groups for these two scores. Return to work was earlier in the S group (34.3 versus 59.7 days; p<0.05)., Discussion: This is the first study reporting the functional results during the first 6 weeks after a displaced fracture of the middle third of the clavicle in adults. Further studies should be conducted to better identify target patients for whom fracture fixation may be beneficial., Conclusion: This study supports open reduction and internal fixation with an anatomical plate of displaced fractures of the middle third of the clavicle since the functional recovery is better in the first 6 weeks., Level of Evidence: III; prospective case-control study., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Improved knowledge of normal shoulder girdle proprioception should benefit the treatment and rehabilitation of shoulder disorders. Whereas many of the available methods for assessing joint position sense (JPS) are costly and complex, Balke et al. have described a simple test. The primary objective of this study was to use this test to identify factors that influence shoulder-girdle JPS evaluation in healthy individuals. The secondary objective was to determine reference values based on the values obtained and on the factors associated with their variability., Hypothesis: Age and dominant limb influence the results of shoulder girdle JPS evaluation, creating a need for reference values that take these factors in account., Patients and Methods: A single-centre prospective study of healthy volunteers was performed between September 2012 and January 2013. In each volunteer, shoulder repositioning accuracy was assessed bilaterally as described by Balke et al. A line was drawn on the floor parallel to and 1 metre away from a wall. A target on the wall showed marks corresponding to three angles of arm elevation: 55°, 90°, and 125°. The volunteer was asked to raise the arm to the three positions, in abduction and in flexion, while memorising the joint positions, then to replicate the same positions with the eyes closed. The absolute differences between the replicated positions and the reference positions, designated angle deviations, were measured in degrees. Age, sex, and dominant upper limb were recorded., Results: The 88 shoulders of 44 healthy volunteers were studied. No significant difference was found between males and females (p>0.05). The only significant difference between sides was better replication by the dominant arm of flexion at 55° (p=0.03). By univariate analysis, age was the only factor significantly associated with repositioning errors (p=0.003); neither dominant limb nor sex were significant (p=0.29 and p=0.59, respectively). In flexion, the angle deviation increased significantly with movement amplitude. The measurements were used to create a chart of expected angle deviations in healthy individuals according to age and to plane and amplitude of movement., Discussion: The test described by Balke et al. is simple and feasible in everyday practice. Age, dominance, and plane of movement should be considered when evaluating abnormal shoulders. Further studies in larger numbers of individuals are needed to better define normal angle deviations related to these factors., Level of Evidence: IV., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: The ageing of the population is steadily increasing the frequency of displaced proximal humerus fractures (PHFs) in elderly patients. The last decade has seen a shift from hemi-arthroplasty (HA) to reverse shoulder arthroplasty (RSA) in these patients. The primary objective of this study was to assess short- and long-term outcomes of RSA in a large cohort of elderly patients with recent PHFs. The secondary objectives were to evaluate radiological outcomes and short- and long-term morbidity and mortality rates., Hypothesis: Outcomes of RSA to treat PHFs in older patients are satisfactory, reliable, and sustained over time., Material and Methods: This retrospective multi-centre study included 898 patients with a mean age of 79 years, among whom 422 underwent a standardised clinical and radiological evaluation at least 1 year after RSA. Some patients were re-evaluated twice. An evaluation within the first 5 years was available for 420 patients (≤5-Y group), whereas 119 patients were re-evaluated more than 5 years after RSA (>5-Y group). Some patients had one re-evaluation either within or after 5 years and others had both an early and a late re-evaluation; thus the total number of re-evaluation was greater than the number of patients., Results: Mean active forward elevation was 115°±29°, mean external rotation with the elbow by the side was 17°±19°, mean internal rotation (hand-to-back) was 4.3±2.5 points, mean absolute Constant score was 57±15, and mean Subjective Shoulder Value was 70%±18%. Re-implantation of the tuberosities followed by healing in the anatomical position was associated with significantly better outcomes, notably regarding rotations. Even in the absence of healing in the anatomical position, tuberosity repair was associated with better clinical outcomes compared to tuberosity excision. Humeral loosening occurred in 3.5% of patients and was associated with tuberosity excision. Glenoid loosening was seen in 3.5% of patients and was associated with superior tilt of the glenoid component. The main complication was prosthesis instability, which occurred in 2.5% of patients, a proportion similar to that seen in the general population. Post-operative patient survival was not significantly different from that in the general population of the same age. Prosthesis survival was 91% after 20 years., Conclusion: Clinical outcomes of RSA for PHF in elderly patients were not only satisfactory but also reproducible and sustained over time. Tuberosity re-implantation around the prosthesis is the key step for optimising the functional outcomes, notably by restoring rotations and decreasing the risk of complications (prosthesis instability and humeral loosening)., Level of Evidence: IV, retrospective observational study., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Introduction: Burnout is a pathology that can affect care-giving professionals. It associates emotional exhaustion (EE), depersonalization (DP) and impaired personal accomplishment (PA). Surgery entails great responsibility and frequently heavy workloads, incurring risk of burnout. Data, however, are not available for French orthopedic and trauma surgeons. We therefore conducted a prospective survey to 1) assess burnout prevalence in French orthopedic surgeons, and 2) investigate risk factors and protective factors., Hypothesis: Burnout prevalence is at least as high in French orthopedic surgeons as in other medical and surgical specialties., Materials and Methods: A nationwide survey was conducted in France between February and April 2017, using a digitized questionnaire sent out by e-mail. Burnout was assessed on the MBI (Maslach Burnout Inventory), and depressive symptoms on the GHQ-12 (General Health Questionnaire-12). Demographic and occupational data were also collected., Results: Out of 1,900 surgeons contacted, 441 (23%) responded. Mean age was 50.2±10.1 years; 413 (93.7%) were male. Sixty one (14%) reported elevated EE, 100 (23%) elevated DP, and 82 (19%) impaired AP. One hundred and seventy two (39%) showed burnout symptomatology (e.g., pathologic score on one MBI scale), while 47 (10%) had pathologic scores on 2 or 3 scales, indicating severe burnout. One hundred and ninety three (43%) would not advise their children to take up orthopedic surgery. Thirty eight (8%) expressed suicidal ideation. Statistical analysis identified public-sector practice (OR=4.6; 95% CI: 2.1-10.7; p=0.0002) and pathologic GHQ-12 score (OR=6.3; 95% CI: 2.2-17.8; p=0.0006) as risk factors for burnout. Outside activity (OR=0.39; 95% CI: 0.1-0.9; p=0.0406) and male gender (OR=0.2; 95% CI: 0.05-0.7; p=0.0160) emerged as protective factors., Discussion: Despite a response rate of only 23% (n=441/1,900), the present study sheds light on burnout rates in French orthopedic surgeons, with 39% burnout symptoms and 10% severe burnout. Burnout impacts personal and occupational life, with increased suicidal ideation and impaired quality of life. The present results confirm the importance of screening and treatment in care-providers., Type of Study: Level IV, prospective descriptive transverse study without control group., (Copyright © 2019. Published by Elsevier Masson SAS.)

Background: Burnout syndrome is one of the manifestations of distress in healthcare workers and is characterised by emotional exhaustion (EE), depersonalisation (DP), and a sense of low personal accomplishment (PA). The surgical residency is a period of intense training that imposes major challenges on future surgeons, who may therefore be at high risk for burnout syndrome. Nevertheless, no data on burnout syndrome in orthopaedic and trauma surgery (OTS) residents in France is available. Therefore we performed a prospective survey to: (1) evaluate the prevalence of burnout syndrome among OTS residents in France, (2) and to look for factors associated with a higher or lower risk of burnout syndrome in the survey respondents., Hypothesis: Burnout syndrome is at least as prevalent among OTS residents in France as among residents in other medical and surgical specialities., Material and Methods: A nationwide prospective survey was conducted in France between February and April 2017 via a digital questionnaire sent by email. Burnout syndrome was evaluated using the Maslach Burnout Inventory (MBI) and symptoms of depression using the General Health Questionnaire (GHQ-12). Demographic data and information on relationships with partners and working modalities were collected., Results: Of 480 OTS residents, 107 (22%) completed the questionnaire. Mean age was 27 years and 65% (n=70) were male. High EE was reported by 26% (n=28), high DP by 63% (n=68), and low PA by 33% (n=36) of respondents. The scores on two or all three of the MBI sub-scales were abnormal, indicating severe burnout syndrome, in 40% (n=43) of respondents. The GHQ-12 scores indicated symptoms of depression in 40% (n=43) of respondents. Furthermore, 61% (n=66) of respondents stated that they would not recommend OTS or any other area of medicine to their children as a career and 10% (n=11) reported suicidal ideation during the past year. The statistical analysis identified three risk factors for burnout syndrome: medical errors (odds ratio [OR], 8.8; 95% confidence interval [95%CI], 1.7-58.7; p=0.0121), symptoms of depression (OR, 19.3; 95%CI, 2.9-196.0; p=0.0048), and living single (OR, 4.7; 95%CI, 1.4-18.9; p=0.0173)., Discussion: Despite the 22% response rate, this study provides useful information on the prevalence of burnout syndrome among OTS residents in France, with severe burnout in 40% and suicidal ideation in 10%. These prevalences may be overestimations, however, as residents who felt under stress may have been more likely to respond to the survey. In published studies, burnout syndrome was associated with higher risks of medical error and suicidal behaviour. These data emphasise the importance of detecting and managing burnout syndrome in healthcare staff., Level of Evidence Iv: Prospective descriptive cross-sectional survey with no control group., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background: Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice., Hypothesis: The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries., Material and Methods: A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries., Results: The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months., Discussion: Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury., Level of Evidence: IV, retrospective observational study., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: The reversed shoulder prosthesis is becoming the gold standard for cases of complex fracture of the proximal humerus after 70 years of age., Material and Methods: The French Society of Orthopaedic and Traumatology Surgery (SOFCOT) conducted a prospective and retrospective multicenter study to evaluate the results of the reversed shoulder prosthesis implanted in patients with a four-part fracture in nine centers. In the retrospective study (n=41 patients, 78 years of age, 14% ASA grade 3, 21% associated fractures) and in the prospective study (n=32 patients, 79 years of age, 37% ASA grade 3, 21% associated fractures) evaluation by independent surgeons was conducted to measure the QuickDASH score, the Constant score, the SSV (subjective shoulder value), and complications to correlate these measurements with radiological results., Results: In both studies, use of an autograft (75%) to perform an osteosuture of tuberosities (90%) and no postoperative immobilization (75%) were similar. In the retrospective study at 39 months (range: 24-62 months) of follow-up, the QuickDASH reached 28 (range: 0-59), the Constant scores (raw Constant=57, weighted Constant=83.4%), and SSV 75 (range: 35-100). Complications after the 1st month (7%) were nonunion or ossifications. In the prospective study at 11 months (range: 5-16.5 months) of follow-up, the QuickDASH reached 40 (range: 1-75), the Constant scores 50 (raw Constant) and 74.6% (weighted Constant), and SSV 69 (range: 10-100). Complications after the 1st month (21%) were stiffness and dislocation, with two patients who underwent revision surgery. In both studies, early complications reached 6% (palsy, dislocation)., Conclusion: This double (retrospective and prospective) study confirms the good results with a low level of complications of the reversed implant in cases of fracture but with osteosuture of tuberosities., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

High-energy injuries to the wrist gather complex fractures of the distal radius, radiocarpal dislocations, perilunate dislocations, and other intracarpal dislocations. Depending on the energy of the injury and the position of the wrist at the time of impact, the patient, often a young male with a high functional demand, presents one of these injuries associating fracture(s) and ligament injury. The trauma is often bilateral, with proximal lesions (elbow) very often associated with contusion or compression of the median nerve. Diagnosis is confirmed by wrist X-rays, which are sufficient to determine treatment for radiocarpal and perilunate dislocations. In cases of distal radius fractures or other intracarpal dislocations, a preoperative CT is necessary. Reduction of the dislocation and relief of neurovascular compression are performed immediately. The final treatment of each lesion (bone fixation, ligament repair) can be undertaken simultaneously or delayed, depending on the patient and the lesions. Cartilage lesions, resulting from the high-energy injury, can be estimated using arthroscopy but cannot be repaired and determine the prognosis. The surgeon's objective is to restore joint congruence, which does not prevent stiffness, the main complication of these rare injuries, which the surgeon must know how to recognize and treat., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: The recurrence rate after primary shoulder dislocation in young subjects with high functional demand is close to 75%. The present study assessed the interest of emergency arthroscopic stabilization in this specific population., Material and Methods: A non-randomized prospective study included 31 athletes under 30 years of age with primary anterior shoulder dislocation. Fifteen were offered emergency stabilization; after informed consent, 14 were enrolled in the "emergency stabilization" group. This was compared to a group matched for age, sport and lesion, managed 1 year previously by "non-operative" treatment (n=17), divided into 2 subgroups: "immobilization" and "secondary stabilization". Continuous prospective assessment of recurrence, return to sport and function (QuickDASH, QDsport, Duplay and Rowe scores) enabled comparison between the 3 groups., Results: Mean follow-up was 19 months for the "emergency stabilization" group and 25 months for the "non-operative" group. There were no failures in the "emergency stabilization" group, compared to a 77% rate in the "non-operative" group with onset at a mean 7.5 months and a mean 2.6 episodes of recurrence. Seven (54%) of the failures of non-operative treatment required secondary stabilization. Ninety-three percent of the "emergency stabilization" group, 44% of the "immobilization" group and 71% of the "secondary stabilization" group resumed sport at least at their pre-dislocation level. Mean Quick DASH was 1.46 in the "emergency stabilization" group, versus 15.28 the "immobilization" group (P<0.05) and 16.96 in the "secondary stabilization" group. Mean Duplay and Rowe scores were respectively 92.9 and 95 in the "emergency stabilization" group, versus 59.44 and 61.1 in the "immobilization" group (P<0.05) and 85 and 93.57 in the "secondary stabilization" group., Discussion: Emergency arthroscopic stabilization limits recurrence (Kirkley et al.), with better functional results than for secondary stabilization, lesion "freshness" providing a more favorable environment for labral and ligamentary healing. These encouraging results need confirmation over longer follow-up., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background: Distal humerus fractures are difficult to characterise and to classify according to the AO system. In this multicentre study, our objectives were to assess the usefulness of computed tomography (CT) and to measure intra-observer and inter-observer reliability according to observer experience., Materials and Methods: An online survey of professional practice was performed using a questionnaire based on a clinical case. Participants were asked to determine the AO classification using radiographs then to reappraise their answers after the addition of CT images. For the reliability study, 16 observers in five centres evaluated radiographs and CT scans of 26 distal humerus fractures. They used the radiographs to determine the AO classification and assess the main fracture characteristics then reappraised their findings after adding the CT images. The radiographs and 2D CT images were read twice at an interval of 2 weeks, and during the second reading, 3D CT images were available also. At least 1 month later, the same observers performed similar readings 2 weeks apart (radiographs and 2D CT images at the first reading and addition of 3D CT images at the second reading)., Results: Correct fracture classification was achieved in 95% of cases with the CT images compared to only 73% with the radiographs. CT led to diagnostic and therapeutic changes in 90% and 25% of cases, respectively. Inter-observer reliability was poor for both AO classification and fracture characteristics, not only with the radiographs and 2D CT images, but also with the added 3D CT images. In contrast, intra-observer reliability improved after the addition of 3D CT images. Assessment accuracy was influenced by image quality and geographic origin of the observer but not by observer experience., Conclusion: CT improves diagnostic accuracy and, in some cases, changes the surgical strategy. In our study of a large number of observers, CT did not improve inter-observer agreement about the study variables. Intra-observer agreement was improved by 3D CT but not by 2D CT. Accuracy was not influenced by years of observer experience but was dependent on image quality, proficiency with computer-based tools and, above all, image observation and interpretation., Level of Evidence: Level III., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Introduction: Fractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study., Materials and Methods: Four hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up., Results: The rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments., Discussion: Complications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome., (Copyright © 2013. Published by Elsevier Masson SAS.)

In patients for whom function is a priority, anatomic reduction and stable fixation are prerequisites for good outcomes. Several therapeutic options exist, including orthopedic treatment and internal fixation with pins (intra- and extrafocal), external fixation which may or may not bridge the wrist, and different internal fixation techniques with dorsal or palmar plates using or not, locking screws. Arthroscopy may be necessary in case of articular fracture. In the presence of significant metaphyseal bone defects, filling of the comminution with phosphocalcic cements provides better graft stability. The level of evidence is too low to allow recommending one type of fixation for one type of fracture; and different fixation options to achieve stable reduction exist, each with its own specific complications. With the new generations of palmar plate, secondary displacement is becoming a thing of the past., (Copyright © 2013. Published by Elsevier Masson SAS.)

Work-related musculoskeletal disorders (WRMSDs) of the upper limb have become a serious concern in many countries and have been steadily progressing for several decades. The cause of WRMSDs is assumed to be the direct consequence of repetitiveness, extreme postures, and intensive efforts in a problematic psychosocial environment. Therapy should therefore associate the occupational physician and the regulatory bodies. It may be necessary to modify the individual workstation and to reorganize the company. Such upper limb pathologies may be surgically treated but the results are often delayed and poorer when compared to the general population., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Split anterior tibialis transfer is a procedure, frequently performed in combination with triceps surae lengthening, to treat equinovarus foot deformity in adult hemiplegia patients. The authors present their surgical technique, with tendon fixation by an anchor to the base of the fifth metatarsal. Although bone-tendon anchor fixation is widespread in orthopedic surgery, it is original in this type of indication. It is simpler, and less traumatic for the bone than a bone tunnel and less traumatic for the sole than transplantar fixation. The very distal attachment to the base of the 5th metatarsal bone solves the common problem of adjusting the tension of tendon transfer. The authors report their experience of 22 split transfers from 2005 to 2008., (Copyright © 2012. Published by Elsevier Masson SAS.)

The "Reamer-Irrigator-Aspirator" (RIA) is a device that provides continuous irrigation and aspiration during intramedullary reaming of long bones. The RIA system is first used to collect the reaming material from medullary cavities, a thick paste of finely morselized osseous particles containing significantly elevated levels of stem cells and growth factors as reported by quantitative analyses. The volume of bone graft material available from an adult femur corresponds to the amount of cancellous bone graft obtained from both the anterior and posterior iliac crests. The assembly and technicalities of the RIA system require a training period to prevent any femoral fracture, which appears to be the major RIA-related complication. The elective indications for RIA bone grafting are filling of bone defects in the epiphyseal and metaphyseal regions. Diaphyseal defects may also be managed using the RIA system provided the graft is placed in a constrained system (induced membrane) to prevent dispersion of the graft into the surrounding soft tissues and is aerated with a porous material to promote its revascularization. Other RIA indications include debriding intramedullary infections and reaming for intramedullary nailing of long bone fractures to reduce the risk of fat embolization., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Unlabelled: The primary goal in treating a degenerative wrist is to provide pain relief, while maintaining strength and mobility if possible. After failure of the recommended conservative treatment, the choice of approaches can be made from a large collection of techniques, some which are well validated. Partial wrist fusion, particularly the Watson procedure, results in a pain-free wrist in 80% of cases, with 50% of the mobility preserved, good grasping strength and stable results for at least 10 years. Proximal row carpectomy provides similar results if the cartilage on the head of the capitate is preserved and the patient is not involved in heavy manual labour. Complete denervation provides pain relief in almost 80% of cases while preserving motion and strength. This is a safe and effective option, with no age limit, that still allows other procedures to be performed in the future. Total wrist fusion also has its place in revision, and even as first-line treatment, because of the reliable outcome in terms of pain and strength, high satisfaction rates, little to no repercussions linked to the loss of mobility and fewer complications. Other techniques are now available. The partial or complete resection of a carpal bone and placement of an implant is back in vogue because of the availability of pyrocarbon. Such implants are an option in the future for localized osteoarthritis or even diffuse affections, and a useful alternative to more invasive procedures. The use of a rib cartilage graft to partially or completely replace a carpal bone or resurface the radius has promising results in terms of pain reduction and fusion. The role of total joint replacement must be defined relative to the classic, reliable techniques that have long-term outcome data., Level of Proof: IV., (Copyright © 2011. Published by Elsevier Masson SAS.)

For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Seven cases of post-traumatic intra-articular malunion of the distal radius treated using costal cartilage graft with a minimum follow-up of 2 years are reported. Location of the articular defect was dorsal in two cases and volar in the others. The approach (dorsal or volar) depended on the main location of the defect. A costal cartilage graft harvested on the eighth rib was implanted in a trough created at the epiphysis metaphyseal junction. This trough removed the defective area on the distal radius articular surface. A plate or wire fixation was used to stabilize in place the graft. Plaster cast wear was prescribed for 3 months in the first case and for 1 month in the other cases following joint reconstruction. No complications were observed. Union was achieved in all seven cases. Graft integration and viability were evaluated with MRI and biopsy. At the longest follow-up, the functional results were excellent in the first (youngest) case (male, 22 years old) in whom motion and grasp were similar to the contralateral side. In the other cases of malunion, the patients were pain-free in daily activities with a functional wrist score of 72/100 (range, 54-82) and a DASH score of 38.3 (range, 22.5-51.7). Only the case with a septic problem failed, with pain reported at follow-up. Reconstruction of a partially destroyed articular surface using a costal graft is reliable and allows filling and resurfacing an articular cartilage void. Although costal cartilage graft is currently used in maxillofacial surgery, this is the first report in post-traumatic osteoarthritis secondary to intra-articular malunion., Level of Evidence: Level IV., (Copyright © 2011. Published by Elsevier Masson SAS.)

Introduction: The present study consisted in a clinical follow-up of patients with distal rupture of the biceps brachii tendon managed by suture anchor reinsertion to the radial tuberosity. Tendon apposition on the cortical bone is the least resistant reinsertion technique according to biomechanical studies. A parallel radiological (X-ray and MRI) study was therefore performed to assess the exact quality of tendon healing and its correlation to clinical results., Patients and Methods: Twenty-eight patients were followed up retrospectively at a mean 22 months (minimum FU: six months) with clinical examination (mobility, force, satisfaction, residual pain, and return to work) and radiological assessment (standard X-ray exploration for heterotopic ossification, and MRI for quality of healing of the tendon apposed to the cortical bone)., Results: Forty percent of cases showed complications (mainly neurological) which resolved without sequelae under medical treatment. Mobility was normal in all but eight patients who showed -5° to -20° supination loss. Force in flexion-supination was 91% of that on the contralateral side. On X-ray, only 46% of patients were free of ossification. On MRI, reinsertion was judged anatomic in 19 patients (70%), moderate in six and poor in two, with one iterative rupture. Statistical analysis revealed that the greater the number of suture tacks through the tendon, the greater the force in patients with less than two weeks' interval to surgery and satisfactory reinsertion on MRI., Discussion: Many reinsertion techniques have been reported, giving clinical results similar to one another and to the present findings. The complications rate, in contrast, varies according to technique and surgical approach. Radiologically, 70% of reinsertions were satisfactory: healing with the tendon apposed on the cortical bone is thus a reliable technique. Heterotopic ossification is considered benign in the literature. The present radiological study refined this notion by identifying three types of ossification: pure asymptomatic intratendon ossification; pure asymptomatic tuberosity ossification without impact on healing on the radial tuberosity; and tuberosity ossification with associated boney metaplasia of the terminal part of the reinserted tendon, impairing healing and leading to less satisfactory clinical results. To ensure anatomic healing of the distal biceps tendon, we recommend less than two weeks' interval to surgery and at least two suture tacks to obtain good apposition on the radial tuberosity., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: Comminuted fractures of the proximal ulna are severe injuries often associated with bone and ligament injuries of the elbow joint (Monteggia lesion, radial head fractures, dislocation of the elbow). The treatment of these fractures is very demanding and the functional results often fairly mediocre due to associated injuries. Based on a single-center retrospective study, we report the results of the treatment of these fractures fixed using a double-plate technique. The aim was to evaluate the feasibility and reliability of this fixation mode and to compare it with other fractures series using a single plate fixation (in terms of bone union, elbow joint function, and complications stemming from the plates)., Patients and Methods: Eighteen patients sustained a comminuted proximal ulna fracture between 2002 and 2006. The fractures were associated in five cases with a Monteggia type lesion, in two cases with elbow dislocation, and in four cases with a Mason 3 radial head fracture. Four patients had an open fracture. These comminuted ulna fractures included nine Mayo Clinic IIIB fractures. Bone fixation was performed with two third-cylinder tubular plates, one plate on each side of the proximal ulna. This allows more versatile solutions for screw insertion. Functional assessment (according to Broberg and Morrey) and radiological evaluation (bone healing) were provided at 6 months and at the longest follow-up by an independent surgeon., Results: Sixteen of 18 patients achieved bone union. No septic complications occurred and no hardware removal was required on patient request. In 67% of the cases, the Morrey score indicated excellent or good results with a mean score of 82., Discussion: There are no reports in the literature on the technical point of fixation concerning complex fractures of the ulna. Two plates mean the possibility of twice the number of screw insertions for epiphyseal reconstruction . This fixation remains easy to perform and provides stable anatomic reconstruction of the ulna., Level of Evidence: Level IV. Retrospective study., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Five consecutive patients (mean age: 40.4 yrs (range, 19-58 yrs)), with symptomatic distal radius malunion underwent corrective opening wedge osteotomy using phosphate cement as an alternative to bone autograft, at a mean 9 months (4-16mo) of fracture. Internal fixation used a plate placed just above the distal radioulnar joint, with soft-tissue release. Radiographic and functional parameters were measured before surgery, and at 6 months and 1 year. At a mean 32.4 months (range, 16-47mo), all patients were satisfied and all the osteotomies were united. At 1 year's follow-up, wrist range of motion reached 75% compared to the contralateral side. Two biopsies performed during plate removal showed osteoid tissue at the cement-bone junction. It is reasonable to consider injectable phosphate cement as a viable alternative to bone grafting in conjunction with surgical correction of distal radius malunion., Level of Evidence: level IV., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Introduction: As population ages, the number of fractures of the proximal humerus in still-active patients is increasing. For three- or four-parts displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment; this technique, however, can lead to catastrophic functional results due to nonunion or tuberosity migration. The present study compared short-term functional results for reverse prosthesis and hemiarthroplasty in complex fractures of the proximal humerus., Hypothesis: In selected complex proximal humerus fractures, the reverse shoulder arthroplasties is a superior treatment option., Patients and Methods: Forty patients were treated by shoulder replacement for three- or four-part displaced fractures of the proximal humerus between 1996 and 2004. Twenty-one had a hemiarthroplasty and 19 were treated by reverse prosthesis. All patients of both groups were reviewed retrospectively by an independent observer. Joint amplitude and Constant score were measured; quality of life was assessed by DASH score. Standard X-ray assessment comprised frontal imaging in three rotation positions and Lamy's incidence., Results: In the hemiarthroplasty group, 17 patients, mean age 74 years (range: 49-95), were followed up for a mean 16.5 months (6-55). In the reverse prosthesis group, 16 patients, mean age 74 years (range: 58-84), were followed up for a mean 12.4 months (6-18). The reverse prosthesis group showed better results in terms of abduction (mean=91 degrees versus 60 degrees), anterior elevation (mean=97.5 degrees versus 53.5 degrees) and Constant score (mean=53 versus 39). Rotation was better in the hemiarthroplasty group (external rotation, 13.5 degrees versus 9 degrees ; internal rotation, 54.6 degrees versus 31 degrees). DASH scores were identical in both groups. X-ray showed three abnormal tuberosity fixations in the hemiarthroplasty group and 15 glenoid notches in the reverse arthroplasty group., Discussion: In three- or four-part displaced proximal humerus fracture, arthroplasty does not ensure recovery of pretrauma shoulder function. Management is therefore to be decided in terms of outcome predictability and rapid recovery of daily comfort for elderly patients. Hemiarthroplasty can provide good functional results, but depends on tuberosity union quality and this often necessitates a prolonged immobilization. Reverse prostheses provide reliable, rapid and predictable results in terms of abduction, anterior elevation and pain relief, but impaired rotation; this impacts quality of life and long-term implant durability (glenoid notching). Reverse prostheses should thus prove advantageous in the treatment of complex fractures of the proximal humerus if these two drawbacks can be resolved and at present seem indicated on condition that the patient is no younger than 70 years of age.