The role of reverse shoulder arthroplasty in management of proximal humerus fractures with fracture sequelae: a systematic review of the literature

Abstract

Fracture sequelae of the proximal humerus poses a complex management decision due to the frequent deformity and its consequences on the peri-articular soft tissues. These patients are frequently elderly with significant medical comorbidities. Due to the age of the patient there is frequently rotator cuff deficiency and therefore the reverse shoulder arthroplasty (RSA) becomes the arthroplasty of choice. We have performed a systematic review of the literature and report nine studies presenting RSA for the treatment of fracture sequelae of the proximal humerus. It is clear that RSA can improve the range of movement and function following proximal humerus fracture sequelae. However, there is a risk of significant complications including dislocation (16.7%), infection (6.7%), intra-operative fracture (3%) and neurological injury (2.6%). There is a need to invest in future prospective comparative studies and randomised trials to further test RSA in fracture sequelae patients. This will provide us with information regarding the longevity of different prosthesis, outcomes and cost-effectiveness of treatment.

SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae

“…Furthermore, whereas most series of PHFS in the literature have been heterogeneous and included RSA for failed hemiarthroplasty, our series is homogeneous. 17,20,28 We believe that our study adds substantially to the existing literature, providing useful information with clear clinical applications for shoulder surgeons.…”

“…Compared with other etiologies (cuff tear arthritis, massive irreparable cuff tear, previous failed cuff repair, and rheumatoid arthritis), the results of RSA for the treatment of PHFS do not appear as good and predictable. 9,13,17,18,20,31,42 The most pertinent finding of our study is that tuberosity osteotomy or excision, performed in patients with type 3 and 4 sequelae (because of severe distortion of the anatomy), is the main reason for poor outcomes, complications, and revision in patients undergoing RSA for PHFS. The functional and subjective results are lower and the rates of complications and revision are significantly higher in patients with types 3 and 4 (extracapsular PHFS) than in those with types 1 and 2 (intracapsular PHFS).…”

“…For instance, our infection rate (1%) is lower than that reported in systematic reviews of RSA for PHFS (6.8%) and is probably underestimated. 20 The reason is that early in our experience, we did not systematically look for associated low-grade infection in patients with fracture sequelae. Despite these limitations, this work represents the largest cohort with this indication with the longest clinical and radiologic follow-up period, with a minimum of 5 years.…”

“…5,6 In the past 10 years, the indications for RSA in treating all types of PHFS have rapidly expanded, with several studies demonstrating some satisfactory but inconsistent short-to intermediate-term results. 1,[20][21][22]24,26,30,43,44 Although RSA can potentially offer an attractive alternative to ASA for the treatment of PHFS, its place has to be more accurately defined and its results, according to the different types of sequelae, must be carefully analyzed. Furthermore, a question remains to be answered: Is tuberosity osteotomy or excision also a prejudicial prognostic factor in RSA for fracture sequelae?…”

Reverse Total Shoulder Arthroplasty for Geriatric Proximal Humerus Fracture Dislocation With Concomitant Nerve Injury

“…This was highlighted in a recent systematic review citing dislocation (16.7%) to be more common than infection (6.8%), perioperative fracture (3.0%), or intraoperative nerve injury (2.6%). 27 Proximal humeral fracture dislocations are also a risk factor for postoperative instability given the associated soft tissue injury to the capsuloligamentous and muscular envelope of the shoulder. Two other studies specifically evaluating rTSA outcomes following proximal humeral fractures in the elderly reported dislocation rates from 6% to 11%, with a propensity for dislocation in those presenting with fracture-dislocations.…”