Assessment of the Efficacy of the Far Cortical Locking Technique for Proximal Humeral Fractures: A Comparison with the Conventional Bicortical Locking Technique

Arthroscopic suprapectoral biceps tenodesis provided earlier shoulder function restoration compared with open subpectoral biceps tenodesis during the recovery phase

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries. Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed. Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates. Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

The shoulder terrible triad (STT) is a traumatic anterior shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the functional results and prognostic factors of surgery in patients with STT. Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity fracture. Variables registered on the day of surgery were preoperative Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator. Twenty-seven patients underwent a complete follow-up. The dominant arm was affected in 50% of cases. The mean follow-up was 27 (12 to 43) months. The mean WORC and Constant scores improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), respectively. The ASES and subjective shoulder value scores at the end of the follow-up were 60 and 56 points, respectively. RC tears and nerve injuries that did not involve the axillary or suprascapular nerves were associated to better results than greater tuberosity fractures and injuries to the axillary or suprascapular nerves, respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES scores (P = 0.035). Preoperative WORC and Constant scores were independent prognostic factors. The most frequent patterns include complete RC tears, anterior capsular injuries, and an axillary nerve injury. Patients had improved functional scores at the end of follow-up after surgery. Better functional results were correlated to RC tears, injuries to nerves with innervation distal to the shoulder, and higher preoperative Constant and WORC scores.

There is biomechanical evidence that bone density predicts the mechanical failure of implants. The aim of this prospective study was to evaluate the influence of local bone mineral density on the rate of mechanical failure after locking plate fixation of proximal humeral fractures. We enrolled 150 patients who were from fifty to ninety years old with a closed, displaced proximal humeral fracture fixed with use of a locking plate from July 2007 to April 2010. There were 118 women and thirty-two men who had a mean age of sixty-nine years. Preoperative computed tomography (CT) scans were done to assess bone mineral density of the contralateral humerus, and dual x-ray absorptiometry of the distal end of the radius of the unaffected arm was conducted within the first six weeks postoperatively. At follow-up evaluations at six weeks, three months, and one year postoperatively, pain, shoulder mobility, strength, and multiple functional and quality-of-life outcome measures (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire; Shoulder Pain and Disability Index [SPADI]; Constant score; and EuroQuol-5D [EQ-5D]) were done and standard radiographs were made. We defined mechanical failure as all complications related to bone quality experienced within one year. After locking plate fixation, fifty-three (35%) of 150 patients had mechanical failure; loss of reduction and secondary screw loosening with perforation were common. CT assessments of local bone mineral density showed no difference between patients with and without mechanical failure (89.82 versus 91.51 mg/cm3, respectively; p = 0.670). One-year DASH, SPADI, and Constant scores were significantly better for patients without mechanical failure (p ≤ 0.05). We did not find evidence of an association between bone mineral density and the rate of mechanical failures, which may suggest that patients with normal bone mineral density are less prone to sustain a proximal humeral fracture. Future studies should target other discriminating factors between patients with and without mechanical failure. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The repair of anterior L-shaped tears is usually difficult because of the lack of anterior rotator cuff tendon to cover the footprint. The biceps tendon is usually exposed from the retracted anterolateral corner of the torn tendon and can be easily used to augment rotator cuff repair. Hypothesis/Purpose: This study compared the clinical outcomes of the biceps augmentation technique with those of partial tendon repair for the arthroscopic treatment of large anterior L-shaped rotator cuff tears to evaluate the role of additional biceps augmentation in tendon healing. We hypothesized that the biceps augmentation technique would lead to a lower rotator cuff tendon retear rate and provide satisfactory functional outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 64 patients with anterior L-shaped rotator cuff tears who underwent arthroscopic repair. Patients were divided into 2 groups: group A (31 patients) underwent repair of an anterior L-shaped tear combined with biceps augmentation, and group B (33 patients) had a partially repaired tendon whose footprint was exposed after repair without undue tension on the retracted tendon. Clinical evaluations were performed using the American Shoulder and Elbow Surgeons (ASES) score, Constant score, muscle strength, visual analog scale for pain, and patient satisfaction. Magnetic resonance imaging (MRI) was performed for tendon integrity at 6 months postoperatively. Results: The mean period of follow-up was 29.1 ± 3.5 months (range, 24-40 months). The mean ASES and Constant scores significantly improved from 52.8 ± 10.6 and 43.2 ± 9.9 preoperatively to 88.2 ± 6.9 and 86.8 ± 6.2 at final follow-up in group A (P < .001) and from 53.0 ± 11.8 and 44.3 ± 11.3 preoperatively to 87.4 ± 7.2 and 87.9 ± 7.3 at final follow-up in group B (P < .001). Overall muscle strength (given as % of the other side’s strength) significantly increased from preoperatively to final follow-up in group A (forward flexion [FF]: 62.0 ± 8.2 to 89.0 ± 8.6; external rotation [ER]: 57.5 ± 9.9 to 86.8 ± 9.3; internal rotation [IR]: 68.1 ± 10.8 to 88.1 ± 8.4; P < .001) and group B (FF: 59.9 ± 9.6 to 87.7 ± 9.0; ER: 58.6 ± 9.3 to 86.2 ± 7.5; IR: 70.0 ± 9.3 to 87.0 ± 8.4; P < .001). Twenty-one patients (67.7%) in group A and 20 patients (60.6%) in group B showed a healed rotator cuff tendon on postoperative MRI. The retear rate between the 2 groups showed no significant difference (P = .552). Regarding clinical outcomes, both groups had no significant difference in the ASES score (P = .901), Constant score (P = .742), and muscle strength. Conclusion: There was no significant difference in the clinical outcomes and retear rate of anterior L-shaped tears between biceps augmentation and partial tendon repair. Additional biceps augmentation proved to have no enhancement in tendon healing. A precise method such as only partial tendon repair for reducing the footprint exposure without undue tension may be considered as one of the treatment options for large anterior L-shaped rotator cuff tears.

Background: The retear rate after primary rotator cuff (RC) reconstruction is high and commonly leads to poorer clinical outcomes and shoulder function. In the case of primary failure, revision RC reconstruction (RCR) has become increasingly important to re-create RC integrity and improve outcomes. To date, clinical and structural outcomes after RCR have not been sufficiently investigated and described at midterm follow-up. Hypothesis/Purpose: The purpose was to evaluate the clinical and radiological outcomes after revision RCR. It was hypothesized that revision RCR significantly improves clinical outcomes and that the outcomes positively correlate with tendon integrity on magnetic resonance imaging (MRI). Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent revision RCR between 2008 and 2014 were retrospectively evaluated with a minimum follow-up of 2 years. Outcomes were assessed by a clinical examination, a visual analog scale for pain (VAS), the Constant Score (CS), the American Shoulder and Elbow Surgeons (ASES) score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Tendon integrity was determined using 3-T MRI and graded according to the Sugaya classification. Results: Thirty-one of 40 patients (77.5%) were available for the final assessment at a mean follow-up of 50.3 ± 20.4 months. Clinical outcome scores significantly improved from preoperatively to postoperatively for the CS (39.7 ± 16.7 to 65.1 ± 19.7; P < .001), ASES (44.2 ± 17.7 to 75.2 ± 24.8; P < .001), and DASH (68.6 ± 15.1 to 21.5 ± 19.1; P < .001). The VAS score decreased from 6.1 ± 1.8 preoperatively to 1.3 ± 1.8 at final follow-up (P < .001). MRI demonstrated a retear rate of 55.5%. No differences in CS, ASES, and DASH scores were detected between patients with an intact repair and failure. Abduction strength was not significantly different in patients with an intact repair and retears (55.5 N vs 44.0 N, respectively, P = .52). Conclusion: Revision RCR improves clinical outcomes and shoulder function at midterm follow-up. The clinical outcome scores were comparable in patients with an intact repair and those with failed RC healing. Therefore, tendon integrity was not correlated with better clinical outcomes after revision RCR at final follow-up.

Background: A few studies have compared high-grade partial-thickness articular- and bursal-side rotator cuff tears postoperatively. Purpose: To compare the clinical and radiological outcomes of high-grade partial-thickness rotator cuff tears treated with arthroscopic conversion to full-thickness tears, followed by repair. Study Design: Cohort study; Level of evidence, 3. Methods: Forty-three consecutive shoulders with high-grade partial-thickness rotator cuff tears (20 articular- and 23 bursal-side lesions) treated with arthroscopic conversion to full-thickness tears, followed by repair using the suture-bridge technique, were evaluated. The final functional evaluation was conducted at a mean of 35.53 months (range, 24-54 months). Radiological outcomes were evaluated at a minimum of 1 year postoperatively. The following outcome measures were used in this study: the American Shoulder and Elbow Surgeons (ASES) score, the University of California, Los Angeles (UCLA) Shoulder Rating Scale, the Constant score, and range of motion. Results: At the final follow-up, the mean ASES, UCLA, and Constant scores improved significantly to 91.80, 32.70, and 75.85, respectively, in the articular-side group (all P < .001). The mean ASES, UCLA, and Constant scores improved significantly to 90.80, 32.52, and 83.00, respectively, in the bursal-side group (all P < .001). The UCLA and ASES scores did not differ significantly between the 2 groups (P = .821 and .869, respectively), while the Constant scores did (P = .048). The retear rate was 0% in the articular-side group and 9.5% in the bursal-side group; this difference was not significant (P = .204). Conclusion: The arthroscopic repair of partial-thickness bursal-side tears resulted in comparable or superior postoperative functional outcomes compared with that of articular-side tears. However, the postoperative retear rate did not differ significantly between the 2 groups.

Reverse total shoulder arthroplasty (rTSA) has become the standard surgical option for managing complex proximal humerus fractures (PHFs) in elderly patients. Despite its widespread use, postoperative functional outcomes remain inconsistent, and patient selection criteria are not well defined. A retrospective cohort study was conducted including 117 patients ≥75 years who underwent rTSA for Neer 3- or 4-part PHFs between 2012 and 2023 at a single tertiary hospital. Preoperative clinical and epidemiological variables were recorded, including Charlson Comorbidity Index, American Society of Anesthesiologists (ASA) score, cognitive status, level of dependence, and availability of social support. Functional outcomes at 12 months were assessed using the Constant and American Shoulder and Elbow Surgeons (ASES) scores. Poor outcome was defined as Constant <45 or ASES <50. Univariate and multivariate logistic regression analyses were performed to identify predictors of poor outcome, and a therapeutic decision algorithm was developed and internally validated. The mean age was 79 ± 7 years (range 75-92), and 80.2% were female. At 12-month follow-up the mean Constant and ASES scores were 55.85 ± 17.7 and 54.6 ± 13.2, respectively. Severe cognitive impairment was the strongest predictor of poor outcome (P < .001), followed by partial dependence (odds ratio [OR] 3.6; 95% confidence interval [CI]: 1.5-8.4; P = .004), lack of social support (OR 4.1; 95% CI: 1.2-13.6; P = .022), and Charlson Index >5 (OR 2.7; 95% CI: 1.1-6.3; P = .027). In multivariate analysis, ASA score remained the only statistically significant independent predictor (OR 0.36; 95% CI: 0.16-0.80; P = .012), while Charlson Comorbidity Index showed a near-significant trend (OR 1.34; 95% CI: 0.996-1.81; P = .053). The resulting predictive model showed good discrimination (area under the curve = 0.78). Preoperative patient-related factors such as ASA score, cognitive status, comorbidity burden, and functional independence significantly influence functional outcomes after rTSA for PHFs in elderly patients. The proposed decision algorithm may enhance surgical decision-making and improve individualized patient care.

This study was designed to longitudinally analyze quantitative intramuscular and perimuscular fat and evaluate clinical outcomes according to healing degree after rotator cuff repair. From June 2013 through October 2018, patients who had undergone repair due to medium-sized rotator cuff tears and serial chest computed tomography (CT) preoperatively and at early (6-12 months) and late (at least 3 years) postoperative follow-ups were included. Supraspinatus (SST) intramuscular fat fraction ratio (IFFR) and perimuscular fat fraction ratio (PFFR) were calculated using chest CT. The rotator cuff integrity was categorized as healed, smaller retear (SRT), and larger retear (LRT) by comparing the preoperative tear size and retear size in shoulder CT arthrography at postoperative follow-ups. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) shoulder rating scale, and the Constant score preoperatively and at early and late postoperative follow-ups. In the LRT group, compared with the preoperative values, there were increases in the SST IFFR and PFFR at the early (p = 0.002 and p = 0.006, respectively) and late (p < 0.001 and p < 0.001, respectively) postoperative time points. Late postoperative clinical scores (UCLA and Constant scores) were not improved compared to preoperative scores (p = 0.156 and p = 0.094, respectively). In the SRT group, there was no difference in the mean SST IFFR and PFFR between preoperative and early postoperative time points (p = 0.766 and p = 0.180, respectively), but the late postoperative values were higher than preoperative values (p = 0.009 and p = 0.049, respectively). Late postoperative clinical scores (ASES, UCLA, and Constant scores) in the SRT group improved compared to preoperative time (p < 0.001, p < 0.001, and p = 0.016, respectively). In the healed group, compared with the preoperative values, there was no difference in the mean SST IFFR and PFFR at postoperative time points; however, the late postoperative clinical scores (ASES, UCLA, and Constant scores) were improved (all p < 0.001). In the SRT group, IFFR and PFFR progressed in the late postoperative period and clinical scores improved over time. However, in the LRT group, IFFR and PFFR progressed in the early and late postoperative periods and clinical scores did not improve at the late postoperative follow-up.

BACKGROUND: The aim of this study was to assess the clinical outcomes after treatment of proximal humeral fractures with locking plates, and to determine which factors influence the clinical and radiological outcomes.METHODS: Fifty six patients who were treated with locking plates for proximal humeral fractures and had been followed for more than 1 year were enrolled in this study. We performed functional evaluation using the Constant score and analyzed radiographic results. The following factors that may potentially influence the clinical outcomes were assessed: age, gender, type of fracture, presence of medial metaphyseal comminution, bone mineral density, anatomical reduction, restoration of medial mechanical support, and postoperative complications.RESULTS: The mean Constant score was 70.1 points at the final follow-up. Female gender, 4-part fractures, AO type-C fractures, and fractures with medial metaphyseal comminution were associated with a poor clinical outcome. On the other hand, restoration of medial mechanical support and accurate anatomical reduction had a positive influence on clinical outcomes. Postoperative complications resulted in 3 patients (intra-articular screw perforation: 1 patient, varus deformity with screw loosening: 1 patient, nonunion: 1 patient).CONCLUSIONS: When treating proximal humeral fractures with locking plate fixation, following factors: a female gender, Neer type 4-part fracture, AO type C fracture, and medial metaphyseal comminution are important risk factors that surgeons should take into consideration. Factors that contribute to better clinical outcomes of operative treatment for humeral fractures are accurate anatomical reduction and restoration of medial mechanical support.

Arthroscopic superior capsule reconstruction (ASCR) using fascia lata autograft is a new surgical technique developed to overcome irreparable rotator cuff tears. There is little information about graft tear after ASCR and its impact on clinical outcome. This study is to investigate the graft tear rate, pattern of failure, and its correlation with clinical outcomes after arthroscopic superior capsule reconstruction (ASCR). From June 2013 to June 2016, 31 shoulders in 31 consecutive patients (mean 65.3years) underwent ASCR using fascia lata autograft for irreparable large-to-massive tears. Magnetic resonance imaging (MRI) was performed before surgery and at mean 12.8months (12-24months) after surgery to assess fatty infiltration progression and graft integrity. Graft tear was defined as the loss of graft continuity and was categorized as medial and lateral rows according to the failure location. Acromiohumeral distance (AHD) was pre- and postoperatively measured with the standard radiograph. Pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, and physical examination were used to assess clinical outcomes. Average follow-up was 15months (range 12-24months) after surgery. Mean active forward elevation increased from 133° to 146° (P = 0.011). Mean VAS score, ASES score, and constant score significantly improved: from 6 to 2.5, 54.4 to 73.7, and 51.7 to 63.7, respectively (P < 0.001). There was no remarkable progression of fatty infiltration after surgery. AHD increased from 5.3mm preoperatively to 6.4mm postoperatively (P < 0.016). Nine patients (29%) showed graft tear on follow-up MRI: 7 and 2at the medial and lateral rows, respectively. Although the intact graft group showed better outcomes than the graft tear group (pain VAS score 2.3 vs. 3.0; ASES score 74.1 vs. 69.8; constant score 63.4 vs. 57.9), the results were not statistically significant. Graft tear rate after ASCR assessed by MRI was 29%, and failures mostly occurred at the medial row. The graft tear group showed clinical improvement despite the recurred superior capsule defect. IV, case series, treatment study.

Background: The preferred patient-reported outcome measure for the assessment of shoulder conditions continues to evolve. Previous studies correlating the Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) to the American Shoulder and Elbow Surgeons (ASES) score have focused on a singular domain (pain or physical function) but have not evaluated the combined domains of pain and physical function that compose the ASES score. Additionally, previous studies have not provided a multivariable prediction tool to convert PROMIS scores to more familiar legacy scores. Purpose: To establish a valid predictive model of ASES scores using a nonlinear combination of PROMIS domains for physical function and pain. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: The Military Orthopaedics Tracking Injuries and Outcomes Network (MOTION) database is a prospectively collected repository of patient-reported outcomes and intraoperative variables. Patients in MOTION research who underwent shoulder surgery and completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at varying time points were included in the present analysis. Nonlinear multivariable predictive models were created to establish an ASES index score and then validated using “leave 1 out” techniques and minimal clinically important difference /substantial clinical benefit (MCID/SCB) analysis. Results: A total of 909 patients completed the ASES, PROMIS Physical Function, and PROMIS Pain Interference at presurgery, 6 weeks, 6 months, and 1 year after surgery, providing 1502 complete observations. The PROMIS CAT predictive model was strongly validated to predict the ASES (Pearson coefficient = 0.76-0.78; R2 = 0.57-0.62; root mean square error = 13.3-14.1). The MCID/SCB for the ASES was 21.7, and the best ASES index MCID/SCB was 19.4, suggesting that the derived ASES index is effective and can reliably re-create ASES scores. Conclusion: The PROMIS CAT predictive models are able to approximate the ASES score within 13 to 14 points, which is 7 points more accurate than the ASES MCID/SCB derived from the sample. Our ASES index algorithm, which is freely available online (https://osf.io/ctmnd/), has a lower MCID/SCB than the ASES itself. This algorithm can be used to decrease patient survey burden by 11 questions and provide a reliable ASES analog to clinicians.

This multicenter retrospective study was conducted with the objective of comparing the outcomes and complications between inlay and onlay reverse shoulder arthroplasty (RSA) in patients presenting Neer Type 4 proximal humerus fractures and cuff tear arthropathy. The primary aim of this investigation was to assess and juxtapose the clinical as well as functional outcomes of individuals who underwent onlay reverse shoulder arthroplasty with those who underwent inlay reverse shoulder arthroplasty. A retrospective cohort study was conducted, involving patients who had undergone reverse shoulder arthroplasty between the period of 2016 and 2022. The study divided the population into two groups: Group A received inlay humeral components, while Group B received onlay humeral components. Functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores. Range of motion, infection, periprosthetic fractures, and nerve injuries were also assessed. The study included 67 patients in Group A and 62 patients in Group B. Group A had significantly better functional outcomes, as indicated by higher ASES and Constant scores (p < 0.05). Group A also had greater shoulder joint motion (p < 0.05). Periprosthetic fractures were significantly more common in Group B (p < 0.05). However, complication rates, including infection and instability, did not significantly differ between the groups (p > 0.05). Nerve injuries occurred in both groups, with slightly higher occurrence in Group B. Inlay humeral components in reverse shoulder arthroplasty for Neer Type 4 fractures and cuff tear arthropathy resulted in better functional outcomes, increased range of motion, and lower incidence of periprosthetic fractures compared to onlay components. Onlay components showed potential advantages in reducing instability rates. Further studies with larger samples and standardized protocols are needed to confirm these findings.

Smokers Achieved Minimal Clinically Important Difference for Visual Analog Scale and American Shoulder and Elbow Surgeons Scores at a Lower Rate Than Nonsmokers Even When Repaired Supraspinatus Tendons Were Intact on Postoperative Magnetic Resonance Imaging

Background: Treatment of unstable, displaced fractures of the proximal end of the humerus has remained controversial in the literature. Conservative treatment often results in stiffness of the shoulder and malunion. Open reduction and internal fixation may result in avascular necrosis of the fragments of the humerus. Fixation of 2- or 3-part proximal humeral fractures with retrograde intramedullary, flexible nails seems to provide appropriate stabilization without further damage to the vascularity of the bony fragments. The purpose of this retrospective study is to evaluate the results of closed reduction and retrograde intramedullary flexible nail fixation of proximal humeral fractures. Patients and Methods: From 1990 to 1998, closed reduction and retrograde intramedullary, flexible nail fixation was performed on a total of 46 patients with 2- or 3-part fractures of the proximal humerus. 10 patients were lost to follow-up. All of the fractures were classified according to the Neer classification. 26 female and 10 male patients with a mean age of 51 years (range: 30-78) were reviewed clinically and radiologically with a mean follow-up of 82 months (range: 42 -44). The shoulder function was evaluated with the Constant scoring system and compared with the opposite shoulder. Radiographic evaluation was done in the anteroposterior, lateral and axillary views of the shoulder after surgery and at final follow-up. Angulation and displacement of the fracture, occurrence of non-union, partial or total avascular necrosis of the head and hardware failure were noted. Results: The mean Constant score was 78 in 3-part fractures and 84 in 2-part fractures at the final follow- up. 91.6 % of the patients were still satisfied with the clinical outcome of the treatment. 3 patients with partial humeral head necrosis were noted. Neither non-union nor total avascular necrosis of the humeral head was noted in any patient. Nail perforation of the humeral head was seen in 14 cases, especially in the elderly. Conclusions: From the results of our study, we suggest that 2-part fractures and minimally displaced 3-part fractures of the proximal humerus can be treated with retrograde, flexible intramedullary nails successfully.