Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly

Abstract

Due to the aging population with poor bone quality the frequency of complex proximal humerus fractures increases. An operative reconstruction and internal fixation is very challenging and is not always possible. Secondary impaction, screw perforations and humeral head necrosis is a common complication. The use of a Reverse Total Shoulder Arthroplasty in the elderly after trauma is a promising alternative. The present multicenter study retrospectively analyzes our long-term experience of reverse total shoulder arthroplasty as a primary treatment in this patient population regarding pain, range of shoulder motion, subjective shoulder value, the constant score, scapular notiching and signs of loosening. Background: Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. Methods: Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). Results: There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. Conclusion:The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome. Level of evidence: Level IV; Case Series; Treatment Study

Reverse shoulder arthroplasty for acute fractures in the elderly: is it worth reattaching the tuberosities?

“…The unreliable results achieved with HA in elderly patients have prompted attempts at treating these patients with the RSA. [8][9][10][11]13,17,20,[22][23][24]27,[29][30][31][32][33][34] The need and potential benefits of tuberosity fixation and healing around such implants remain controversial, and low rates of tuberosity healing (as low as 40%) 8,13,17,20,32 have been reported in some published series of RSA for fractures in the elderly population. Moreover, because the RSA can overcome cuff deficiency, 2 some authors have recommended not reattaching or even excising the tuberosities in RSA for displaced PHFs.…”

“…[8][9][10][11][12]16,21,[23][24][25][27][28][29][30]33 Cazeneuve et al, 11 in a series of 30 acute fractures treated with a RSA without tuberosity reattachment, reported 2 patients with instability, 2 with implant loosening, 1 with infection, and 7 with proximal humeral bone lysis. Klein et al 20,21 reported 2 early infections and 2 dislocations in a series of 20 fractures treated with a RSA and excision of the tuberosities. Gallinet et al 16 compared 18 patients with tuberosity healing in an anatomic position vs. 24 without tuberosity repair or with nonunion or malunion of the tuberosities.…”

“…8,21,[23][24][25]27,29,33,35 Some authors have recommended not reattaching or even excising the tuberosities when treating PHFs with a RSA 11,12,16,21 ; however, severe complications, such as instability, infection, and implant loosening, have been reported when the tuberosities do not heal around the reverse stem. 9,16,21,23,24,[27][28][29]34,35 Although recent studies have shown that tuberosity healing in the elderly is associated with better range of motion and function, 13,17,20,32 the rates of tuberosity healing vary from 40% to 84% in this elderly population. Thus, a question still remains and needs to be answered: is it worth reattaching the tuberosities in RSA for acute fractures in the elderly?…”

Reverse total shoulder versus angular stable plate treatment for proximal humeral fractures in over 65 years old patients

“…During the last decennium the use of RSAs has increased, both as a salvage procedure after failed hemi-arthroplasty but also in the primary fracture care. RSA has gained popularity and has showed promising results in the treatment for proximal humeral fractures in the elderly patients 14,31,32 . A recent large database analysis of 32.150 shoulders underlined the growing importance of RSA in treating proximal humeral fractures in elderly, stating that from 2009 to 2012 the utilization rate of RSA nearly tripled for patients over 65 years old, passing from 11% to 29% of treatment choices, to the disadvantage of HA and a steady trend of ORIF 33 .…”

A scale-space curvature matching algorithm for the reconstruction of complex proximal humeral fractures

“…The treatment of comminuted fractures of the proximal humerus is challenging and the optimal procedure remains controversial ( Cvetanovich et al, 2016;Gerber et al, 2004 ). Open reduction and internal fixation using conventional or locking plates is the mainstay of therapy for the young and active patient ( Gerber et al, 2004;Grubhofer et al, 2016 ), while best results are obtained if anatomical or near anatomical reduction can be achieved ( Gerber et al, 2004 ). Anatomical reduction is a pre-requisite for a joint-preserving surgical treatment of a fractured proximal humerus.…”