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Surgical technique
Three different techniques were developed, each being
adapted to the anatomic complexity of the fractures: (1)
the minimally invasive (percutaneous) approach, (2) the
standard approach, and (3) the cup-and-ball approach. Operations with all techniques were done with the patients in
the beach chair position and with intraoperative fluoroscopic control.
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Figure 1 A, Radiograph and (B) drawing show the humeral fracture repaired with a Telegraph nail. The commonly used assembly
has 2 frontal screws.
with an elevator or pin used as a joystick. A 15- to 20-mm incision was made in the skin over the front of the acromion. A
small incision was made in the rotator cuff, 10 to 15 mm
medial to its insertion, directly over the central axis of the medullary canal of the humerus. An awl and then a reamer were
introduced at the top of the articular surface of the head. With
the fracture reduced, the nail with the attached jig was then
inserted. A C-arm was used to check the reduction of the
fracture and the position and height of the nail. The proximal
interlocking screws were inserted percutaneously using a softtissue sleeve. Distal locking was optional.
Patients
The present series consisted of 67 patients (50 women
and 16 men) aged older than 50 years (average age,
72.1; range, 50-92 years) who were part of a larger prospective analysis of patients who had surgery between
1998 and 2000. The complete prospective series included
122 patients of all ages treated for proximal humeral fractures using this implant. The right shoulder was involved in
54%, and the mechanism of injury was low-energy trauma
in 94%. Associated fractures occurred in 13.8% of the cases
and included proximal femur and wrist fractures. Seventeen
patients were lost to follow-up and 27 died, leaving 78 patients who were followed up after surgery for an average
of 48 months (range, 42-55 months). Of these, 67 fractures
were in patients aged older than 50 years. Special attention
was given to the follow-up of the 27 patients (25 women)
older than 75 years because the outcome in this group
may be influenced by osteoporosis. In this subset of 27 of
the most elderly patients, 17 had extraarticular fractures, 4
had impacted articular injuries, and 4 had unstable fractures
or fracture-dislocations.
The rough Constant score3 was used to evaluate the results of treatment and was adjusted by age and sex. The radiologic results were analyzed from radiographs of the
shoulder using anteroposterior (AP) and lateral scapula
views.8,18,20 The bone healing and the anatomic features
of the repair were assessed by the inclination angle of the humeral head on the AP view (normal, 45 ) and on the lateral
view (normal, 30 ). Any migration of the tuberosities was
noted. The difference in height between the proximal tip of
the greater tuberosity and the outer articular border of the humeral head was measured. The presence of avascular necrosis (AVN) was noted by the loss of head sphericity. Screw
penetration was defined when the distance between the tip
of the implant and the subchondral bone was less than 2 mm.
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Figure 2 A, Radiograph at admission shows a valgus impacted fracture with large posterior displacement in an 83year-old woman. B, First control radiograph after repair with Telegraph nail. C, Radiograph at 5-years follow-up
(Constant score, 54).
RESULTS
Functional results
Figure 3 Reduction of the head with an elevator and temporary fixation with a Kirschner wire inserted on the glenoid.
All fractures were classified using the Arbeitsgemeinschaft Fur Osteosynthesefragen (AO) system16 in 3 groups
of fractures (Table I). The extraarticular fractures, including
the 2- or 3-part surgical neck fractures with varying displacement, are represented by the A2, A3, Bl, and B2 varieties
and accounted for 40 patients (60%). The second group
included articular valgus impacted fractures12 (Cl) and
involved 11 patients (16%). The third group included
16 patients (24%) with complex intraarticular fractures
The average rough Constant score at the 4-year follow-up was 62 (standard deviation, 20). The average
sex- and age-weighted Constant score was 93.5% for
the extraarticular surgical neck fractures, 85% for the
impacted-valgus articular fractures, and 77.5% for the
disengaged or dislocated fractures, or both. The raw
data are reported in Table I. In the patients aged older
than 75 years, the average rough Constant score was
60 and the weighted Constant score was 89% (standard deviation, 20%). Three cases of AVN occurred
in this age group, all after intraarticular fractures.
Radiologic evaluation
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Cuny et al
Figure 4 A, Admission radiograph shows a complex disengaged fracture in 81-year-old woman. B, First control
radiograph after repair with the Telegraph nail. C, Radiograph at the 3-year follow-up (Constant score 79).
Complications
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Figure 5 The cup-and-ball technique. A, Complex fracture. B, Distal locking without reduction. C, Removal of the
jig. D, Reduction and fixation of the head. E, Reduction and fixation with intraosseous sutures of tuberosities.
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Cuny et al
40 (59.7)
4 (8)
11 (16.4)
2 (18)
2 (18)
16 (23.9)
6 (37.5)
7 (43.7)
Weighted
93.5%
85%
77.5%
Overall, the data presented in this study bring objective information about this type of osteosynthesis,
and we recommend the use of the Telegraph nail in
selected cases.
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