Reverse shoulder arthroplasty in acute fractures of the proximal humerus: A systematic review

The indications for surgical intervention in complex fractures of the proximal humerus are disputed. In elderly patients with poor bone stock it may be impossible to obtain satisfactory fixation of the tuberosities to a hemiarthroplasty (HA). In such cases primary insertion of a reverse shoulder arthroplasty (RSA) has been suggested. We aimed to review clinical studies reporting benefits and harms of RSA in acute fractures. A systematic review. We included 18 studies containing 430 RSA in acute fractures. We found no randomized clinical trials. Four studies compared outcome after RSA with a historical control group of HA. The median constant score was 58 (range 44-68) which is comparable to previous reviews of HA in 4-part fractures. Complications included dislocation, infection, hematoma, instability, neurological injury, reflex sympathetic dystrophy, intraoperative fractures, periprosthetic fractures, and baseplate failure. Scapular notching was reported in 11 studies with a median value of 25% (range 0-94). Heterogeneity of study designs and lack of primary data precluded statistical pooling of data. No high quality evidence was identified. Based on the available evidence the use of RSA in acute fractures is questionable. The complication rate was high and the clinical implications of long term scapular notching are worrying. Randomized studies with long term follow up using the latest techniques of tubercular reinsertion in RSA toward HA should be encouraged.     

Proximal humerus fractures should be treated with a reverse shoulder replacement

Historically, fractures of the proximal humerus not amendable to closed treatment or internal fixation have been treated with hemiarthroplasty. Clinical outcomes following hemiarthroplasty have been variable and difficult to predict. Results are often correlated with increasing age, tuberosity healing, and tuberosity position. Reverse shoulder arthroplasty has demonstrated effectiveness in elderly patients with rotator cuff arthropathy and has been increasingly employed for complex fractures in older patients. Several small trials have compared the reverse arthroplasty and hemiarthroplasty for acute fractures, and reverse shoulder arthroplasty has demonstrated more reproducible results in elderly patients.     

Comparison of functional outcomes of reverse shoulder arthroplasty versus hemiarthroplasty in the primary treatment of acute proximal humerus fracture

Background: Treatment of complex proximal humeral fractures remains controversial. In cases where adequate open reduction and internal fixation cannot be achieved, hemiarthroplasty has been the traditional treatment; however, clinical results have been mixed. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative, and this study aimed to compare the functional results of RSA versus hemiarthroplasty in patients with acute proximal humeral fracture. Methods: Ten patients with acute proximal humerus fractures unsuitable for internal fixation (mean age 77) who underwent RSA for acute proximal humerus fracture unsuitable for internal fixation against the outcomes of 10 patients (mean age 75) who had previously undergone hemiarthroplasty for the same indication. Functional scores and radiographic outcomes were assessed at 22–44 months follow up. Results: At follow up the mean American Shoulder and Elbow Scorev score was 65 (range 40–88) in the RSA group and 67 (26–100) in the hemiarthroplasty group. Mean Oxford Shoulder scores were 29 (15–56) and 22 (12–34), respectively. Mean forward elevation was 115 degrees (range 45–140 degrees) and active external rotation was 49 degrees (5–105 degrees) in the RSA group, versus 108 degrees (50–180 degrees) and 48 degrees (10–90 degrees) in the hemiarthroplasty group. No statistically significant differences in outcome scores or range of motion were seen. Conclusion: In these early results, the anticipated functional gains of RSA over hemiarthroplasty were not realized, suggesting the use of RSA for treatment of proximal humeral fractures should remain guarded. Larger prospective trials are necessary to identify the optimal management of patients in this situation.     

The effect of body mass index on functional outcome,pain, and postoperative complications in shoulder arthroplasty after a proximal humerus fracture

BackgroundAlthough shoulder arthroplasty often gives a reliable improvement in shoulder pain and function after proximal humeral fractures (PHFs), one must consider the risk of complications. The purpose of this study was to investigate whether body mass index (BMI) is associated with an increased risk of complications or worse postoperative shoulder function after reverse shoulder arthroplasty (RSA) or hemiarthroplasty (HA) in patients with PHF.MethodsThis study included 233 patients who underwent HA or RSA after PHF in the Ryhov Teaching Hospital between 2006 and 2018. Data collected include age, gender, BMI, preoperative and postoperative Constant score, preoperative and postoperative visual analogue scale (VAS) score during rest and activity, postoperative complications, and patient satisfaction.ResultsAnalysis was made in HA and RSA patients separately. The HA and RSA patients were divided into three groups based on their BMI. Group I consisted of patients with a BMI <25 kg/m², group II consisted of patients with a BMI between 25 and 29.9 kg/m², and group III consisted of patients with a BMI > 30 kg/m². We found no statistically significant difference between BMI groups regarding postoperative Constant score, postoperative VAS score during rest, postoperative VAS score during activity, postoperative complications, and patient satisfaction in neither HA patients nor RSA patients.ConclusionThis study showed that BMI did not affect the risk of postoperative complications or bad functional outcome after treatment of PHF with HA or RSA.     

Anatomic versus reverse shoulder arthroplasty for post-traumatic sequelae of operatively and nonoperatively treated proximal humerus fractures

BackgroundThis study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF.MethodsA prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively.ResultsThere were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037).ConclusionFor treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management.Level of evidenceLevel III; Retrospective Cohort Design; Treatment Study     

Periprosthetic humeral fractures in shoulder arthroplasty

Periprosthetic fractures associated with shoulder arthroplasty are uncommon but can be very difficult to treat. Treatment options depend on the timing of the fracture, the type of fracture, and the stability of the implant. Understanding these characteristics of periprosthetic fractures helps the practicing surgeon to avoid them and also to determine how best to manage them when they do occur.