Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures

Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report

Background

Proximal humeral fracture is the third most common fracture in elderly people after fractures of proximal femur and distal radius. They typically occur after low-energy trauma in women affected by osteoporosis, bilateral involvement is rare and usually with a simple pattern of fracture. Bilateral four-part proximal humerus fractures are even less frequent, with only a few reports published previously, with all of them caused by a seizure or electrocution in patients < 65 years old.

Case presentation

We present a 77-year-old right-handed female that sustained a bilateral simultaneous four-part humeral fracture secondary to accidental slip-and-fall occurred at home. Patient was treated with simultaneous bilateral Reverse Shoulder Arthroplasty (RSA) in our structure. Functional assessment was undertaken at 6- and 12-months follow-up (FU) after surgery, using the Constant-Murley score (CMS) and the Disabilities of the Arm, Shoulder and Hand (DASH) score.

Outcome

The simultaneous RSA procedure was well tolerated by the patient. Post-operative course was optimal with relatively low blood loss, rapid functional recovery, and fast pain relief. The CMS and DASH score were reasonably good at 6-months FU (right-left: 39–57 and 50.8–30.5, respectively) and they further improved at 1-year FU (right-left: 66–82 and 35.8–19.2, respectively). X-rays showed good position of the implants with no evidence of scapular notching at 1 year. Patient rated the overall satisfaction as good.

Discussion

Bilateral four-part proximal humeral fractures are complex injuries difficult to manage. Optimal treatment is controversial, and it can be conservative or surgical, varying from open reduction and internal fixation (ORIF) to arthroplasty. However, this last option is still directed to only one side, preferring ORIF or conservative treatment for the contralateral. In case of comminute and displaced fractures, low bone quality, rotator cuff deficiencies and eccentric osteoarthritis, RSA is to prefer as a surgical option. For these reason, in selected cases of bilateral four parts proximal humerus fracture, especially when occurs in elderly patients, the simultaneous RSA implantation can represent a valid option to achieve an adequate functional result and a fast recovery. This is the first description, to our knowledge, in English literature of a simultaneous bilateral RSA.

Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement

BACKGROUND

The purpose of this study was to determine whether thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) score exist that predict excellent patient satisfaction after reverse shoulder arthroplasty (RSA).

METHODS

Patients undergoing RSA with a single implant system were evaluated preoperatively and at a minimum 2-year follow-up. Receiver operating characteristic curve analysis determined thresholds to predict excellent patient satisfaction by evaluating the percentage of maximal improvement for SST and ASES scores. Preoperative factors were analyzed as independent predictors for achieving SST and ASES score thresholds.

RESULTS

There were 198 (SST score) and 196 (ASES score) patients who met inclusion criteria. For SST and ASES scores, receiver operating characteristic curve analysis identified 61.3% (P < .001) and 68.2% (P < .001) maximal improvement as the threshold for maximal predictability of excellent satisfaction, respectively. Significant positive correlation between the percentage of maximum score achieved and excellent patient satisfaction for both groups was found (r = 0.440 [P < .001] for SST score; r = 0.417 [P < .001] for ASES score). Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the SST and ASES score threshold.

CONCLUSION

Thresholds for the achievement of excellent satisfaction after RSA were 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement. Independent predictors of achieving these thresholds were dominant-sided surgery and higher baseline visual analog scale pain scores for the SST score and rotator cuff arthropathy for the ASES score.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results

BACKGROUND

On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome.

MATERIALS AND METHODS

Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed.

RESULTS

A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients.

CONCLUSION

This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

Exploring elderly patients' experiences of recovery following complex proximal humerus fracture: A qualitative study

This study explores the experiences and perceptions of recovery in elderly patients who had sustained a proximal humerus fracture. In-depth semi-structured interviews were conducted with 15 patients over the age of 65. Thematic analysis identified aspects of care that impacted upon patient experience and quality of life. Seven main patient-reported themes were identified, including pain, sleep, shoulder function, emotional state, social support, relationship with their professional and experience of healthcare institution. These themes offer insight into the experiences of adults receiving care for proximal humerus fracture and highlight that existing quantitative measures of quality of life do not measure domains that are important to patients.

The increasing role of reverse total shoulder arthroplasty in the treatment of proximal humerus fractures

INTRODUCTION

Hemiarthroplasty of the shoulder is a well established treatment for proximal humerus fractures not amenable to open reduction internal fixation. However, orthopedic surgeons have recently increased utilization of reverse total shoulder arthroplasty (RTSA) in the treatment of these injuries. The purpose of this study was to evaluate the use of hemiarthroplasty and RTSA between 2009 and 2016 for the treatment of proximal humerus fractures within a large United States integrated healthcare system.

MATERIALS AND METHODS

A descriptive study was conducted using our integrated healthcare system's Shoulder Arthroplasty Registry. Shoulder arthroplasty cases performed for an acute proximal humerus fracture between the years of 2009 and 2016 were identified. Revision rates were determined, as well as changes in age and gender distribution of the cohort during the study period.

RESULTS

In 2015, RTSA utilization surpassed that of hemiarthroplasty for the first time in the healthcare system. The utilization of RTSA in the treatment of proximal humerus fractures increased from 4.5% of all arthroplasties in 2009 to 67.4% of arthroplasties in 2016. During the study period, patients undergoing hemiarthroplasty were younger and less likely to be female. Crude revision rate was 4.0% for hemiarthroplasty and 3.2% for RTSA.

CONCLUSIONS

RTSA is increasingly being utilized for the treatment of proximal humerus fractures and now appears to be the treatment of choice. While hemiarthroplasty appears to be falling out of favor in the treatment of fractures of the shoulder, surgeons may still be preferentially using the procedure in younger patients.

Tuberosity healing after reverse shoulder arthroplasty for complex proximal humeral fractures in elderly patients-does it improve outcomes? A systematic review and meta-analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus in older patients. Anatomic tuberosity healing in RSA has been recognized to restore better shoulder function. We compared the reported clinical and functional outcomes of RSA in proximal humeral fractures with and without tuberosity healing.

METHODS

We performed a systematic review of literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials. We included all studies with RSA for proximal humeral fractures in patients older than 60 years and compared outcomes based on tuberosity healing with minimum follow-up of 12 months.

RESULTS

Seven studies met the inclusion criteria. A total of 381 patients (382 shoulders) were identified. There were 53 men (18.3%) and 236 women (81.7%), with mean age of 76.83 years (range, 74-81 years). Mean follow-up duration was 29.84 months (range, 24-90 months), and the mean rate of greater tuberosity healing was 70.5%. Patients with healed tuberosity had significantly better active forward flexion (134.1° vs. 112.5°, P < .05), abduction (114.8° vs. 95.1°, P < .05), external rotation with elbow by the side (27.8° vs. 7.6°), and mean Constant score (63.5 vs. 56.6, P < .05) than with those with nonhealed tuberosity.

CONCLUSION

The RSA group with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity group. Tuberosity healing may influence overall shoulder function after RSA for proximal humeral fractures in the elderly, and this needs verification with future prospective studies.

Effect of Tuberosity Healing on Clinical Outcomes in Elderly Patients Treated With a Reverse Shoulder Arthroplasty for 3- and 4-Part Proximal Humerus Fractures

OBJECTIVES

To evaluate tuberosity union rate and clinical outcome after 3- and 4-part proximal humerus fractures in the elderly.

DESIGN

Retrospective, multicenter database cohort study.

SETTING

Level I and Level II trauma centers.

PATIENTS

Fifty-five patients older than 65 years had insertion of reverse shoulder arthroplasty (RTSA) for OTA/AO 11-B and 11-C proximal humerus fractures.

INTERVENTION

Treatment with RTSA using a dedicated low profile onlay fracture stem using variable tuberosity fixation.

MAIN OUTCOME MEASURES

Constant score, the American Shoulder and Elbow Surgeons score, Shoulder Pain and Disability Index score, University of California at Los Angeles score, Simple Shoulder Test score, visual analog pain score, shoulder function score, active range of motion, external rotation (ER)-specific tasks and position, rate of greater tuberosity healing, effect of tuberosity healing on overall clinical metrics, incidence of humeral lucency, and scapular notching.

RESULTS

Eighty-three percent of the greater tuberosities that were repaired united. Greater tuberosity union resulted in greater active ER (P = 0.0415). There was a statistically significant difference in the ability to do ER-type activities between the 2 cohorts reflected in the ability to position one's hand behind their head with the elbow forward (P = 0.002) and comb their hair (P < 0.001).

CONCLUSION

The use of a low profile onlay fracture stem in RTSA for acute 3- and 4-part proximal humerus fractures in the elderly can result in a high tuberosity union rate. Greater tuberosity healing significantly influences ER and ER-type activities that are not apparent by analysis of the overall metrics studied.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice

OBJECTIVES

The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden.

METHODS AND FINDINGS

The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011.

CONCLUSIONS

There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.

Subscapularis Peel for Open Reduction and Internal Fixation of Proximal Humerus Fractures With a Head Split

Proximal humerus fractures involving an articular head split are rare and complex injuries. In the elderly population, arthroplasty is the optimal treatment, whereas in younger patients, the utility of arthroplasty procedures is limited by concerns of long-term implant survival. As a result, open reduction and internal fixation is still often the first-line treatment option for head-splitting injuries. The traditionally described deltopectoral or anterolateral surgical approaches to the proximal humerus rely on indirect reduction and limited visualization of the articular fragments. We present a case series of younger patients with head-split proximal humerus fractures treated with open reduction and internal fixation through a deltopectoral approach with a subscapularis peel to improve humeral head visualization, reduction, and fixation. The improved reduction may lead to better long-term outcomes and reduce the need for additional surgical procedures. In addition, there were no cases of avascular necrosis in this series.

Grammont versus lateralizing reverse shoulder arthroplasty for proximal humerus fracture: functional and radiographic outcomes

PURPOSE

The aim of this study is to retrospectively compare clinical and radiographic outcomes of patients treated with non-lateralizing reverse shoulder arthroplasty (RSA) and with humeral lateralizing RSA after proximal humerus fracture (PHF).

METHODS

In total, 32 patients (8 men and 24 women), with a mean age of 77.4 (67-92), have been reevaluated (follow-up of 14.3 months) and divided into Grammont group (G-group-16 patients, 2 men and 14 women, mean age 82.3) and lateralizing group (L-group-16 patients, 4 men and 12 women, mean age 72.5). The dominant side was affected in 21 patients. Pain, Constant-Murley score (CMS), range of motion accurately measured with inertial sensors (SHoWlder, NCSLab^®) and complications. Anatomic tuberosity healing, signs of loosening or mobilization of the implants and scapular notching (according to Sirveaux classification) have been measured on standard X-ray series (antero-posterior view in neutral, external and internal rotation; axillary view; outlet view).

RESULTS

Similar CMS was recorded between the two groups (G-group: 61/100; L-group: 64/100). G-group had higher forward flexion (128° vs. 112°) and abduction (126° vs. 114°), L-group had higher external rotation in abduction (35° vs. 41°); similar internal rotation (sacrum) and rotation with elbow in adduction were measured (12° vs. 19°). No statistically significant differences emerged. Anatomic healing of the tuberosity was higher in G-group (87.5% vs. 50%); low-grade scapular notching was higher in L-group (18.25% grade 1-2 vs. 0). Anatomic healed tuberosity guaranteed highly statistically significant improved functional outcomes. No revisions of the implant were performed.

CONCLUSIONS

RSA can be considered a valid solution for the treatment of PHF in elderly low-demanding population. Cuff conditions should be investigated before surgery for the indication of the adequate model.

Reverse shoulder arthroplasty vs BIO-RSA: clinical and radiographic outcomes at short term follow-up

Background

Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) may address issues such as inferior scapular notching, prosthetic instability and limited postoperative shoulder rotation; all of which have been reported with the standard RSA and attributed to the medialized design. We hypothesised that this lateralization may increase the rate of scapular stress fractures.

Methods

A retrospective review of prospectively collected data was performed on patients who had undergone a RSA between January 2013 and October 2016. A comparative cohort study was designed to compare patients with a standard Grammont-style RSA to those with a BIO-RSA using the same implant. Functional outcome was measured by the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the Subjective Shoulder Value (SSV), the Western Ontario Osteoarthritis of the Shoulder (WOOS) index and pain scores. Radiographs were obtained for all patients and examined for the presence of scapular fracture as well as scapular notching and graft incorporation.

Results

A total of forty patients (22 patients in the standard RSA cohort and 18 with BIO-RSA) were included in the study. Patient characteristics (including age, gender, length of follow-up, dominant side and osteoporosis) were similar in both groups (p > 0.05). The average postoperative follow-up was 20 months (range 12–48 months). There was bone graft incorporation in all BIO-RSA patients at the final radiological follow-up, with no evidence of graft resorption. The overall scapular stress fracture rate was 12.5% (9.1% in the standard RSA and 16.7% in the BIO-RSA). The rates were similar in both cohorts (p = 0.64). All fractures were managed conservatively. To determine whether the presence of a scapular stress fracture had an influence on outcomes, the cohort was divided into cases with and without fracture. Patients with a stress fracture had worse ASES (p = 0.028) and WOOS (p = 0.048) scores. Additionally, osteoporosis was present more commonly in the fracture group (80% vs 17%; p = 0.01). A statistically significant difference was identified when comparing the rates of scapular notching between standard RSA and BIO-RSA cohorts (68% vs 33%; p = 0.028). Furthermore, when notching was present, significantly worse outcome scores were present in all outcome measures (p < 0.001).

Conclusion

The BIO-RSA technique was associated with an increase in scapular stress fracture rate when compared to the standard RSA; however, this was not found to be significant. Furthermore, both techniques resulted in similar improvements in the measured functional outcomes. BIO-RSA, however, was associated with a lower scapular notching rate, justifying further evaluation of this technique.

Level of evidence

Retrospective cohort study, level III

Is reverse total shoulder arthroplasty more effective than hemiarthroplasty for treating displaced proximal humerus fractures in older adults? A systematic review and meta-analysis

INTRODUCTION

The indications for surgical treatment of displaced proximal humerus fractures in older patients have gradually changed in the past 10 years: fewer hemiarthroplasty (HA) procedures but more reverse shoulder arthroplasty (RSA) procedures are being done. The aim of this study was to determine the clinical and radiological outcomes, the complications, reoperations and revisions of RSA and to compare them with those of HA.

MATERIAL AND METHODS

A systematic review of the literature published between January 2006 and February 2016 was carried out to identify studies reporting or comparing results of HA and RSA for proximal humerus fractures in patients above 65 years of age. These studies were classified based on their quality and level of evidence. Of the 67 studies that were identified and reviewed, 22 were chosen for the analysis.

RESULTS

The functional outcome (Constant score) after RSA is significantly better and more reproducible that the one obtained after HA. RSA provides significantly better active range of motion in forward flexion and abduction than HA. Conversely, active internal and external rotation are worse after RSA than HA. Reattachment of the tuberosities around the RSA improves the rotation ability. Even if the tuberosities do not heal, the functional outcomes are satisfactory after RSA but not HA due to a major functional deficit. The tuberosity healing rate around the RSA does not decline with age, contrary to HA where age is a negative factor. The overall complication rate is higher after RSA than HA; however the reoperation rate is equal. The revision rate for implant change is higher after HA.

CONCLUSION

Compared to HA, RSA provides more reproducible function with better recovery of active forward flexion and abduction, even when the tuberosities are not reattached or do not heal properly. The poor rotation ability can be improved by reinserting the tuberosities. While the complication rate after RSA is higher than after HA, the reoperation rate is equal, and the revision rate is lower.

LEVEL OF EVIDENCE

IV, Systematic review of literature.

Return to Play After Shoulder Replacement Surgery: What Is Realistic and What Does the Evidence Tell Us

This article analyzes the available literature regarding return to sport following total shoulder arthroplasty (TSA), hemiarthroplasty (HA), and reverse shoulder arthroplasty (RTSA). It examines the quality of the available evidence and areas of future research. Most patients are able to return to preoperative sport activities following TSA, RTSA, and HA. The rates of return for TSA are slightly higher than those reported for HA and RTSA. Patients may be counseled that noncontact, low-demand activities have higher return rates. Most patients can expect to return to sports within 6 months postoperatively.

Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures

BACKGROUND

This study evaluates the clinical outcomes in patients with proximal humerus fractures (PHF) treated with reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed fixation that have more than 5 years of follow-up.

MATERIALS AND METHODS

This is a retrospective study of 270 RTSA. The inclusion criteria for this study consisted of patients initially treated with either open reduction and plate fixation (ORIF) or fixation using an intramedullary nail (IMN), who were managed with a single-stage revision to a RTSA, and had a minimum of 24 months clinical and radiological follow-up. Six patients with failed fixation of displaced PHF were revised with RTSA. One patient was excluded from the study because she died. Five shoulders were reviewed for the purpose of this study. The patients were evaluated using Constant score, relative Constant score and visual analogue scale for pain.

RESULTS

The mean follow-up was 89 months (65-108). The mean absolute Constant score improved from 31, 81 to 44, 2 and the relative Constant score improved from 31,81% to 67,2%. Mean VAS improved from 6, 8 to 2. One patient rated their outcome excellent, 1good, 1 satisfied and 2 poor.

CONCLUSION

RTSA is an appropriate treatment as a revision surgery for failed fixation of PHF. Patients should be adequately warned that they will improve their function but may have complications following this salvage procedure.

Current Trends in the Use of Shoulder Arthroplasty in the United States

Reverse total shoulder arthroplasty (rTSA) has become increasingly popular since its introduction to the United States. The purpose of this study was to assess the current trends and use of rTSA, anatomic total shoulder arthroplasty (aTSA), and hemiarthroplasty (HA) from 2011 to 2014. Shoulder arthroplasty data from the National (Nationwide) Inpatient Sample database were analyzed for the years 2011 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. For each procedure, use and patient and hospital characteristics were identified. Shoulder arthroplasties increased by 24% between 2011 and 2014, to 79,105 procedures. The proportion of arthroplasties that were aTSA did not change substantially (44% for both years; P=.0585), while the proportion that were rTSA surpassed aTSA in 2014, increasing from 33% to 46% (P<.0001). Use of rTSA topped use of aTSA by 2013 for Medicare patients. The proportion that were HA procedures declined from 23% to 11% (P<.0001). The use of rTSA for fracture increased from 26% to 58% (P<.0001) of all arthroplasties for this indication, while the use of HA for fracture decreased from 69% to 40% (P<.0001). Orthopedists performed rTSA more often than aTSA for Medicare patients by 2013 and the general population by 2014. The use of rTSA for fracture has grown significantly, with rTSA being performed more frequently than HA for this indication. [Orthopedics. 2018; 41(3):e416-e423.].

Massive Rotator Cuff Tear: When to Consider Reverse Shoulder Arthroplasty

PURPOSE OF REVIEW

The purpose of this review is to discuss the indications for reverse shoulder arthroplasty (RSA) in the treatment of massive rotator cuff tear (MCT), review the reported outcomes in the literature, and outline our approach and surgical technique for treating these patients.

RECENT FINDINGS

While RSA remains a successful and well-accepted treatment for cuff tear arthropathy (CTA), management of MCT in the absence of arthritis is controversial. In this particular setting, patients best suited for RSA are elderly, lower-demand individuals with chronic, irreparable MCT, and pseudoparalysis. Age < 60, better pre-operative function and upper extremity neurologic dysfunction are potential risk factors for poor outcome with RSA in this population. Long-term follow-up studies of RSA for CTA and MCT show good functional outcomes and implant survival > 90% at 10 years. Treatment of MCT must be individualized for each patient. When patient selection is optimized, RSA is a reliable means of relieving pain and improving function with excellent success. Further investigation is necessary to better define its indications and assess the role of alternative, joint-salvaging procedures.

Reverse total shoulder arthroplasty

Since the introduction of reverse total shoulder arthroplasty (RTSA) in 1987 (in Europe) and 2004 (in the United States), the number of RTSAs performed annually has increased.

Although the main indication for RTSA has been rotator cuff tears, indications have expanded to include several shoulder conditions, many of which involve dysfunction of the rotator cuff.

RTSA complications have been reported to affect 19% to 68% of patients and include acromial fracture, haematoma, infection, instability, mechanical baseplate failure, neurological injury, periprosthetic fracture and scapular notching.

Current controversies in RTSA include optimal baseplate positioning, humeral neck-shaft angle (135° versus 155°), glenosphere placement (medial, lateral or bony increased offset RTSA) and subscapularis repair.

Improvements in prosthesis design, surgeon experience and clinical results will need to occur to optimize this treatment for many shoulder conditions.

Cite this article: EFORT Open Rev 2018;3:58–69 DOI: 10.1302/2058-5241.3.170044

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982-e989.].

Humeral Head Replacement and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fracturesm

Acute proximal humeral fractures in the elderly are generally treated non-operatively if alignment is acceptable and in stable fracture patterns. When operative treatment is indicated, surgical fixation is often difficult or impossible to obtain. Hemiarthroplasty has long been the standard of care. However, with its reliance on tuberosity healing, functional outcomes and patient satisfaction are often poor. Reverse shoulder arthroplasty has emerged as a new technology for treating proximal humeral fractures but the indications for its use remain uncertain. While not conclusive, the evidence suggests that reverse shoulder arthroplasty yields more consistent results, with improved forward elevation and higher functional outcome scores. The primary advantages of hemiarthroplasty are improved shoulder rotation and shorter operative time. Complication rates do not vary significantly between the two options. Although higher quality trials are needed to further define the role of reverse shoulder arthroplasty, current evidence suggests that this is a reasonable option for surgeons who are highly familiar with its use.

A New Stem Guide and a Tuberosity Anchoring "Lasso" System for Shoulder Hemiarthroplasty in the Treatment of Complex Proximal Humerus Fractures

Hemiarthroplasty implantation for proximal humerus fracture is challenging. In case of young demanding patients with functional rotator cuff, humeral head replacement is an option if open reduction internal fixation is not a viable solution. The criteria for success in terms of clinical outcomes and longevity are anatomic healing of the tuberosities and stem positioning (restoring correct height, version, and axis). The purpose of this article is to describe a technique including a new stem guide and a tuberosity anchor "lasso" system for the implantation of hemiarthroplasty in complex proximal humerus fractures. A standard delto-pectoral approach is performed. After humeral head removal and tuberosity mobilization and debridement, a stem-positioning system guarantees correct height and version of the humeral stem, established after anatomic reduction of the greater tuberosity. A centering device is added on the humeral stem to prevent any varus or valgus. Fixation of the tuberosities is achieved with 6 nonabsorbable sutures fixed on a polyester "lasso" anchoring system circling the humerus, respecting the direction of rotator cuff tendons and adding double circumferential tightening. After reduction of the implant, stability, and passive range of motion are assessed intraoperatively and fluoroscopic control of the prosthesis is performed. The patient is maintained in a sling in neutral rotation and passive motion is started after 4 weeks; active motion is allowed after 2 months. We believe this surgical technique could help limit complications and prevent revision of the humeral stem in case of further conversion to reverse shoulder arthroplasty.

Reverse shoulder arthroplasty compared with hemiarthroplasty in the treatment of acute proximal humeral fractures

BACKGROUND

Complex proximal humeral fractures may require prosthetic replacement of the humeral head. Surgical options include reverse shoulder arthroplasty (RSA) and shoulder hemiarthroplasty; however, the optimal technique remains controversial. The goal of this study was to compare functional outcomes and revision rates of RSA with hemiarthroplasty in patients with acute proximal humeral fractures.

MATERIALS AND METHODS

Between January 1, 1999, and December 31, 2014, there were 218 patients who underwent RSA and 427 who underwent hemiarthroplasty for acute proximal humeral fractures identified through New Zealand Joint Registry records. Study groups were compared with regard to baseline characteristics, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS], revision rate, mortality rate) at 6 months and 5 years after surgery.

RESULTS

RSA patients were significantly older (mean age, 78.2 vs. 71.6 years; P < .001), with a higher proportion of female patients (90% vs. 77%; P < .001) than in the hemiarthroplasty group. No statistically significant difference existed in revision rate per 100 component-years (0.58 [RSA] vs. 1.16 [hemiarthroplasty]; P = .137) or 1-year mortality (3.8% vs. 3.4%; P = .805) between both groups. There was no significant difference in 6-month OSS (29.6 vs. 28.4; P = .305). The RSA group demonstrated a superior mean 5-year OSS (37.6 vs. 32.7; P = .078); however, the difference did not achieve statistical significance.

CONCLUSIONS

Although our results suggest that RSA patients may experience superior 5-year functional scores, we have identified no significant difference in functional outcomes and revision rates between RSA and hemiarthroplasty in the treatment of acute proximal humeral fractures.

Outcomes of Reverse Total Shoulder Arthroplasty for Proximal Humeral Fractures: Primary Arthroplasty Versus Secondary Arthroplasty After Failed Proximal Humeral Locking Plate Fixation

OBJECTIVE

To compare the outcomes of reverse shoulder arthroplasty (RSA) between patients with failed proximal humeral locking plate (PHLP) fixation and those with acute fractures.

DESIGN

Matched case-control study.

SETTING

University hospital, Level I trauma center.

PATIENTS

Thirty consecutive patients with fracture sequelae because of failed PHLP fixation (mean age 73) were age and sex matched to 30 patients with acute fracture (mean age 75).

INTERVENTION

All patients underwent RSA.

MAIN OUTCOME MEASUREMENTS

Constant, University of California Los Angeles (UCLA) and Disability of the Arm, Shoulder and Hand (DASH) scores. Radiological assessments were also performed.

RESULTS

The mean postoperative follow-up was 3.2 (range, 2-5) years. All functional scores significantly improved from preoperative to postoperative (P = 0.001) in the sequelae group. Pain was relieved in all but one patient, and all but 2 patients were satisfied with their RSA. However, the functional outcomes at the last follow-up were significantly worse in the sequelae group compared with acute group in terms of adjusted Constant (P = 0.013), UCLA (P = 0.020) and DASH (P = 0.048) scores, strength (P = 0.01), anterior forward (P = 0.021), and abduction (P = 0.007). Six patients (20%) in the sequelae group had complications including 2 intraoperative (diaphyseal false passages), 2 early dislocations, 1 acromial fracture, and 1 aseptic loosening of glenoid component. Four of these patients were revised resulting all in a successful outcome at the last follow-up. In the acute group there was one intraoperative humeral fracture with no impact on the final outcome.

CONCLUSIONS

Patients with failed PHLP fixation for fracture who were revised to RSA secondarily obtained marginally lower functional scores and higher complication rates compared with patients treated with primary RSA for fracture. However, patients who treated with secondary RSA had significant functional improvement and pain relief compared with their preoperative status, and most complications were manageable without a significant effect on final outcome.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical management of complex proximal humeral fractures: pinning, locked plate and arthroplasty : Clinical results and functional outcome on retrospective series of patients

PURPOSE

The aim of the study was to compare the clinical results and related complications of four different surgical treatments of complex proximal humeral fractures according to their classification and features of patients.

METHODS

Between 2007 and 2011, 92 consecutive patients with diagnosis of three-four-part displaced fractures, fractures with head dislocation and head-splitting fractures were evaluated postoperatively with Constant-Murley score, disability of arm, shoulder and hand score and simple shoulder test.

RESULTS

All the treatment modalities showed from optimal to good mean functional results. The statistical analysis comparing each treatment group showed better outcomes scores (p < 0.05) for: locked plating versus HA, locked plating versus RSA and RSA versus HA. No differences between postoperative range of motion, complication rate and overall revision rate of the treatment groups were found at the end of follow-up (p > 0.05). Overall complication rate of surgical treatment of complex PHF was 31.5% (29 patients) with overall revision rate of 14.1%. Among patients with complications 77.8% of HA (7 of 9) required revision surgery (p < 0.05).

CONCLUSIONS

The treatment of complex PHF is nowadays a challenge even for skilled shoulder surgeons. The several viable operative options give good results whenever used for the correct indication. The range of reported complications from 18.2 to 37.5% remains concerning, but most of them did not affect clinical outcome in this series. Accurate preoperative characterization of the fracture pattern is necessary, and high surgical skills of the different operative techniques, including arthroplasty, are recommended to meet the increased functional expectations of patients.

LEVEL OF EVIDENCE

Therapeutic series, Level IV.

[Not Available]

Zusammenfassung. Zusammenfassung: Die Komplikationsrate nach Osteosynthese von proximalen Humerusfrakturen ist trotz neu entwickelten Implantaten hoch. Wir sind der Meinung, dass die hohe Individualität der Patienten auch einen möglichst individuellen Therapieansatz benötigt. Somit definierten wir einen evidenzbasierten Behandlungsalgorithmus, der die Patientenindividualität und das ganze Behandlungsspektrum beinhalten sollte. Wir suchten dabei nach einem optimalen Weg zwischen Risiko (Komplikationen) und Ertrag (Schulterfunktion). Vor allem die Lebensqualität sollte nach der Frakturbehandlung wieder möglichst gut sein. Die ersten Resultate unserer prospektiven Untersuchung sind vielversprechend. Die konservativen Wege im Algorithmus scheinen gut zu funktionieren, nur sehr selten musste davon abgewichen werden. Es zeigt sich jedoch, dass vor allem die Osteosynthesen noch immer komplikationsbelastet sind. Diesbezüglich gilt es, den Algorithmus und die chirurgische Technik in Zukunft noch zu verbessern.

A comparative analysis of work-related outcomes after humeral hemiarthroplasty and reverse total shoulder arthroplasty

BACKGROUND

The return to work of young patients undergoing shoulder arthroplasty is increasingly important. Whereas studies have shown superior outcomes of reverse total shoulder arthroplasty (RTSA) compared with humeral hemiarthroplasty (HHA), no prior literature has compared RTSA with HHA in regard to return to work.

METHODS

A retrospective review of a prospectively collected shoulder arthroplasty registry was performed to analyze all patients who underwent RTSA or HHA at a single institution. A validated questionnaire evaluating return to work postoperatively was administered at baseline and at follow-up in addition to the American Shoulder and Elbow Surgeons and visual analog scale (VAS) pain surveys.

RESULTS

The study included 40 RTSA and 41 HHA patients. The average age at surgery was 68.6 years in the RTSA group and 60.8 years in the HHA group (P < .001). Postoperatively, 65% of RTSA patients returned to work compared with 70.7% of HHA patients (P = .64). There was no significant difference in the time to return to work between the RTSA (2.3 months) and HHA (3.1 months) groups (P = .46). Both groups had statistically significant improvements in both the American Shoulder and Elbow Surgeons and VAS scores. The improvement in pain on the VAS for patients undergoing RTSA (-5.6) trended toward significance compared with HHA (-4.2) (P = .056).

CONCLUSION

Roughly two-thirds of patients undergoing either HHA or RTSA were able to return to work postoperatively, with no significant difference found between the 2 groups in terms of time to return to work, despite that patients undergoing RTSA were significantly older.

Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults

BACKGROUND

The treatment of 3- and 4-part proximal humeral fractures in the older adult is controversial. No study has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for these fractures. The purpose of this study was to compare clinical and patient-reported outcomes between RSA and nonoperative treatment groups.

METHODS

A retrospective review was performed on all 3- and 4-part proximal humeral fractures treated with either RSA or nonoperative treatment with minimum 1-year follow-up. All patients in the nonoperative cohort were offered RSA but declined. Objective patient data were obtained from medical records. Patient-reported outcomes including visual analog scale score, Single Assessment Numeric Evaluation score, Penn Shoulder Score, American Shoulder and Elbow Surgeons score, resiliency score, and Veterans Rand-12 scores were obtained at follow-up. Statistical analysis was performed by use of the Student t test for continuous variables and χ² analysis for nonparametric data.

RESULTS

We analyzed 19 nonoperative and 20 RSA patients with a mean follow-up period greater than 2 years (29 months in nonoperative group and 53 months in RSA group). There were no differences in range of motion between groups (forward elevation, 120° vs 119° [P = .87]; external rotation, 23° vs 31° [P = .06]). No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes. Among patients receiving RSA, there was no difference in outcomes in those undergoing surgery less than 30 days after injury versus those receiving delayed RSA.

CONCLUSIONS

This study suggests that there are minimal benefits of RSA over nonoperative treatment for 3- and 4-part proximal humeral fractures in older adults.

Bilateral reverse total shoulder arthroplasty-functional outcome and activities of daily living

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs.

METHODS

Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient's satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits.

RESULTS

Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling).

CONCLUSION

Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities.

A Cost-Effectiveness Analysis of Reverse Total Shoulder Arthroplasty versus Hemiarthroplasty for the Management of Complex Proximal Humeral Fractures in the Elderly

BACKGROUND

There is ongoing debate regarding the optimal surgical treatment of complex proximal humeral fractures in elderly patients.

OBJECTIVES

To evaluate the cost-effectiveness of reverse total shoulder arthroplasty (RTSA) compared with hemiarthroplasty (HA) in the management of complex proximal humeral fractures, using a cost-utility analysis.

METHODS

On the basis of data from published literature, a cost-utility analysis was conducted using decision tree and Markov modeling. A single-payer perspective, with a willingness-to-pay (WTP) threshold of Can$50,000 (Canadian dollars), and a lifetime time horizon were used. The incremental cost-effectiveness ratio (ICER) was used as the study's primary outcome measure.

RESULTS

In comparison with HA, the incremental cost per quality-adjusted life-year gained for RTSA was Can$13,679. One-way sensitivity analysis revealed the model to be sensitive to the RTSA implant cost and the RTSA procedural cost. The ICER of Can$13,679 is well below the WTP threshold of Can$50,000, and probabilistic sensitivity analysis demonstrated that 92.6% of model simulations favored RTSA.

CONCLUSIONS

Our economic analysis found that RTSA for the treatment of complex proximal humeral fractures in the elderly is the preferred economic strategy when compared with HA. The ICER of RTSA is well below standard WTP thresholds, and its estimate of cost-effectiveness is similar to other highly successful orthopedic strategies such as total hip arthroplasty for the treatment of hip arthritis.

Cement technique correlates with tuberosity healing in hemiarthroplasty for proximal humeral fracture

BACKGROUND

Tuberosity healing correlates with clinical outcomes after hemiarthroplasty for 4-part proximal humeral fractures (4PHFs). We seek to examine variables that affect tuberosity healing.

METHODS

This was a retrospective comparative study. At 1 year postoperatively, patients who underwent hemiarthroplasty for 4PHFs were divided into 2 groups: those with anatomically healed tuberosities and those with tuberosity nonunion. The primary variables included time between injury and surgery, prosthesis fenestration, cement mantle classification, and both vertical and horizontal tuberosity reduction. Secondary demographic factors included age, gender, osteoporosis status, diabetes status, and smoking status.

RESULTS

There were 84 individuals who met the inclusion criteria: 37 (44%) had anatomically healed tuberosities, and 47 (56%) did not. Individuals with anatomic healing had cement near or under the tuberosities 32% of the time, whereas individuals with nonunion or resorption had cement near the tuberosities 66% of the time (P = .002). There was no association between tuberosity healing and fenestration of the humeral stem (P = .84). Anatomic reduction between tuberosities was associated with healing (P <.001), whereas greater tuberosity-to-head height was not (P = .25). There were no significant differences in age, osteoporosis status, smoking status, diabetes status, or time to surgery between groups. Male patients had nearly double the rate of healing (P = .03).

DISCUSSION AND CONCLUSION

The classification and effect of cement technique on tuberosity healing have not previously been described. We suggest limiting cementation to a minimum of 5 mm below the level of the tuberosity fracture. The ideal candidate for hemiarthroplasty for a 4PHF is a male patient with anatomic tuberosity reduction and limited use of cement.

Primary reverse shoulder arthroplasty in patients aged 65 years or younger

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has classically been reserved for patients older than 65 years with rotator cuff arthropathy, pseudoparalysis, and severe pain. This investigation assessed outcomes in a consecutive series of patients aged 65 and younger undergoing primary RTSA.

METHODS

There were 63 patients (67 shoulders; 40 women, 27 men) with a mean age of 60 years (range, 50-65 years). Indications were cuff tear arthropathy (CTA) in 51, severe glenohumeral arthritis in 15, and osteonecrosis in 1. The primary end point was revision-free implant survival. Pain scale, motion, strength, and radiographic outcomes were also studied.

RESULTS

At a mean follow-up of 3 years (range, 2-8 years), the 2-year and 5-year revision-free survival was 99% and 91%, and reoperation-free survival was 97% and 90%, respectively. Complications occurred in 9%. Smoking increased the risk for revision, reoperation, and complications (P < .03). Patients experienced improvements in pain (P < .0001), active abduction (57.5° vs. 132.4°, P < .0001), and active external rotation (20.1° vs. 39.4°, P < .001). At the most recent follow-up, 90% patients were satisfied with their result, and 85% felt they were better or much better than before surgery. There was an 18% incidence notching, 3% incidence of dislocation, and no loosening.

CONCLUSIONS

At both 2 and 5 years, RTSA is a reliable operation in patients aged younger than 65 years. Patients gain significant improvements in pain level, range of motion, and strength, without a large number of early failures. Long-term follow-up is needed to understand late component mechanical problems and loosening.

[Shoulder endoprosthesis in the elderly : Hemiarthroplasty or total shoulder arthroplasty? Anatomic or reverse?]

Implantation of reverse shoulder endoprostheses is becoming more popular for elderly patients besides the well-established standard anatomic endoprostheses. The reasons for this are the increased life expectancy, age-dependent degeneration of the rotator cuff leading to cuff tear arthropathy, posttraumatic disability after failed osteosynthesis and primary reverse fracture arthroplasty. Stemless implants are more frequently used for primary osteoarthritis with the bone quality being the limiting factor. Modern implant systems allow the stepwise extension from bone preserving primary implants to modular and convertible revision implants that allow a partial exchange of components. Revision surgery, especially that of reverse arthroplasty, has limited potential for secondary treatment options and therefore implantation and revision should be performed in specialized treatment facilities.

Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture

BACKGROUND

Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture.

HYPOTHESIS

RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury.

DESIGN

Retrospective case series.

MATERIAL AND METHODS

Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse.

RESULTS

At final follow-up, average active elevation was 135° (range 110°-145°), abduction 122° (range 60°-160°), and external rotation 30° (range 0 to 45°). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series.

DISCUSSION/CONCLUSION

RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure.

LEVEL OF EVIDENCE

III.

Effectiveness and Safety of Interventions for Treating Adults with Displaced Proximal Humeral Fracture: A Network Meta-Analysis and Systematic Review

Purpose

Network meta-analysis (NMA) is a comparatively new evidence-based technique in medical disciplines which compares the relative benefits associated with multiple interventions and obtains hierarchies of these interventions for various treatment options. We evaluated the effectiveness and safety of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), intramedullary nailing (IN) and non-operative treatment (NOT) of displaced proximal humeral fractures in adults using Bayesian NMA of data from clinical trials.

Method

PUBMED, EMBASE and CENTRAL in July 2016 were searched and clinical trials that evaluated interventions for treating adults with displaced proximal humeral fractures were identified. Methodological qualities of studies were assessed by the Newcastle—Ottawa Scale and risk of bias using the Cochrane Collaboration tool.

Result

Thirty-four trials involving 2165 participants were included in the study. RSA had significantly the highest Constant score and lower total incidence of complications than ORIF, HA and IN. Moreover, RSA resulted in a lower incidence of additional surgery than ORIF and IN. The rank of treatments in terms high Constant score was: RSA, ORIF, IN, NOT and HA. The rank for reduction in total incidence of complications was: RSA, NOT, HA, IN and ORIF. For lowering the risk of additional surgery, the rank was: RSA, NOT, HA, IN and ORIF.

Conclusion

RSA had the highest probability for improving functional outcome and reduction in the total incidence of complications and requiring additional surgery among the five interventions for treating adults with displaced proximal humeral fracture.

Return to sports after shoulder arthroplasty

Many patients prioritize the ability to return to sports following shoulder replacement surgeries, including total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA), and hemiarthroplasty (HA). While activity levels after hip and knee replacements have been well-established in the literature, studies on this topic in the field of shoulder arthroplasty are relatively limited. A review of the literature regarding athletic activity after shoulder arthroplasty was performed using the PubMed database. All studies relevant to shoulder arthroplasty and return to sport were included. The majority of patients returned to their prior level of activity within six months following TSA, RTSA, and shoulder HA. Noncontact, low demand activities are permitted by most surgeons postoperatively and generally have higher return rates than contact sports or high-demand activities. In some series, patients reported an improvement in their ability to participate in sports following the arthroplasty procedure. The rates of return to sports following TSA (75%-100%) are slightly higher than those reported for HA (67%-76%) and RTSA (75%-85%). Patients undergoing TSA, RTSA, and shoulder HA should be counseled that there is a high probability that they will be able to return to their preoperative activity level within six months postoperatively. TSA has been associated with higher rates of return to sports than RTSA and HA, although this may reflect differences in patient population or surgical indication.

Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study

INTRODUCTION

Complex 4-part fractures of the proximal humerus are one of the most difficult fractures to manage. For several years, reverse total arthroplasty (RSA) has been proposed as an alternative to hemiarthroplasty (HA) when internal fixation is insufficient. The goal of this study was to compare the short and intermediate term results of these 2 different types of arthroplasty.

MATERIALS AND METHODS

In a retrospective, multicenter study, 57 HA and 41 RSA were reviewed after a follow-up of at least 2 years. The clinical evaluation was based on the absolute and adjusted Constant scores, Simple shoulder value (SSV) and the quick-DASH scores. The radiological assessment included standard radiological tests.

RESULTS

After a mean follow-up of 39 months, the RSA group had a significantly higher adjusted Constant score than the HA group (83% vs 73%, respectively P=0.02). However, there was no significant difference in the absolute Constant score, the quick-DASH or the SSV scores. Active anterior elevation was better in the RSA group, while internal rotation was better in the HA group (130° vs 112°, P=0.01; sacrum vs L3, P=0.03). There was no significant difference in external rotation (28° vs 23°, P=0.31). The rate of complications was higher in the HA group than in the RSA group (24% vs 10%, P=0.01). The radiological rate of union of the greater tuberosity was similar in both groups (70%) and scapular notching was found in 23% of the RSA group.

CONCLUSION

The short and intermediate term clinical outcomes are better with RSA than with HA. The complication rate is higher with HA. Nevertheless, scapular notching occurred in more than 20% of patients with RSA, suggesting that care should be taken when using this prosthesis in young, active patients.

Causes of poor postoperative improvement after reverse total shoulder arthroplasty

BACKGROUND

Although reverse total shoulder arthroplasty (RTSA) has been successful in improving pain and function in most patients, some patients fail to improve clinically. The present study used a large registry of RTSA patients to evaluate associations between patient-related factors and poor postoperative improvement after RTSA.

MATERIALS AND METHODS

A prospectively collected shoulder arthroplasty registry was queried for consecutive patients who underwent RTSA from 2007 to 2013. Patients with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. Poor postoperative improvement was defined as a change in the ASES of less than 12 points. Multivariate logistic regression analysis was used to identify independent risk factors.

RESULTS

A total of 150 patients met inclusion and exclusion criteria. Logistic regression revealed that male sex (adjusted odds ratio [OR], 7.9; P = .004), presence of an intact rotator cuff at the time of surgery (adjusted OR, 4.8; P = .025), depression (adjusted OR, 11.2; P = .005), a higher baseline ASES score (P < .001), and higher total number of medical comorbidities (P = .035) were associated with poor postoperative improvement after RTSA.

CONCLUSIONS

Surrogates for better preoperative function after RTSA, such as a higher baseline ASES score and intact rotator cuff at the time of surgery, correlated with poor postoperative improvement. In addition, male sex, depression, and total number of medical comorbidities also correlated with poor postoperative improvement. Interestingly, factors such as patient age and indication for surgery were not found to correlate with poor improvement after RTSA.

Outcomes of reverse total shoulder arthroplasty as primary versus revision procedure for proximal humerus fractures

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has been shown to be an effective treatment for proximal humerus fracture (PHF). This study evaluates outcomes of all patients with PHF treated with RTSA as a primary procedure for acute PHF, a delayed primary procedure for symptomatic PHF malunion or nonunion, a revision procedure for failed PHF hemiarthroplasty (HA), or a revision procedure for failed open reduction and internal fixation (ORIF).

METHODS

Patients who underwent RTSA for PHF were evaluated for active range of motion and Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test-12, American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA) shoulder rating scale, Constant, and 12-Item Short Form Health Survey scores. Scaption and external rotation (ER) strength were also assessed.

RESULTS

RTSA was performed in 49 patients with PHF; 13 patients underwent RTSA for acute PHF, 13 for malunion or nonunion, 12 for failed PHF HA, and 11 for failed PHF ORIF. ER range of motion, SPADI, ASES, UCLA, and Constant scores achieved significance. The acute fracture group significantly outperformed the failed HA group in SPADI, ASES, and UCLA scores. The malunion/nonunion group significantly outperformed the failed HA group in ASES and UCLA scores. The acute fracture and malunion/nonunion groups each had significantly greater ER than the failed HA group.

CONCLUSION

RTSA is an effective treatment option for PHF as both a primary and a revision procedure. Primary RTSA outperformed RTSA done as a revision procedure. RTSA for acute PHF is comparable to RTSA for malunions and nonunions. Our outcomes of revision RTSA for failed HA and ORIF are more promising than previously published.

Cost Analysis of Hemiarthroplasty Versus Reverse Shoulder Arthroplasty for Fractures

Complex proximal humerus fractures in older patients can be treated with hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA), with both providing good pain relief and function. This study compared the costs, complications, and outcomes of HA vs RSA after proximal humerus fracture in older patients. Patients 65 years or older who were admitted between January 2007 and August 2011 with a 3- or 4-part proximal humerus fracture and treated with HA or RSA were identified. Surgeries were performed at the same institution by 1 of 3 surgeons trained in trauma or shoulder surgery. Operating room costs, implant costs, total costs to the patient and hospital, and range of motion were compared. In the study group, 8 patients (7 women and 1 man; mean age, 77 years) received HA and 16 patients (13 women and 3 men; mean age, 77 years) received RSA. Hemiarthroplasty implant cost and operating room cost were $9140 and $8900 less than those of RSA, respectively (P<.001). The total cost to the patient was $33,480 for HA vs $57,000 for RSA (P<.001) with no difference in admission length, transfusion requirements, or final range of motion. In patients with complex proximal humerus fractures, RSA restored function similar to HA and resulted in better pain and outcome scores. However, RSA had a significantly higher cost to both the patient and the hospital compared with HA. Further investigation of postsurgical rehabilitation costs, skilled nursing needs, or revision surgery will elucidate whether there is long-term functional or financial benefits to RSA over HA. [Orthopedics. 2016; 39(4):230-234.].

Reverse total shoulder arthroplasty for the management of fractures of the proximal humerus: a systematic review

Reverse total shoulder arthroplasty (RTSA) represents a good solution for the management of patients with fracture of the proximal humerus with associated severe osteoporosis and RC dysfunction. A systematic review of the literature according to the PRISMA guidelines was performed matching the following keywords: "reverse total shoulder arthroplasty"; "reverse total shoulder prostheses"; "fractures"; "fracture of the proximal humerus." Medline, EMBASE, Google Scholar, and Ovid database have been screened. Ten studies were considered in the qualitative analysis. No randomized prospective controlled trials have been found. A total of 256 patients received a RTSA for the management of fracture of the proximal humerus. There were 28 males (10.8 %) and 228 females (89.2 %). The mean age of patients was 75.5 ± 2.2 years (range 70-78 years). The mean follow-up period was 27.8 ± 21.8 months range (6-86 months). Overall, the mean Constant score was 56.7 ± 7.6 points (range 44-67.8 points), the mean DASH score was 39.9 ± 6 points (range 31.5-46.8 points), the ASES averaged 70.3 ± 6.8 points (range 65-78 points), and the OSS averaged 28.7 points (range 15-56 points). RTSA restores function and relieves pain in patients with proximal humeral fractures. However, no randomized controlled trials are available to support RTSA versus osteosintesis, anatomical prostheses or hemiarthroprotesis. Further studies are needed to evaluate the effectiveness of RTSA in the management of fracture of the proximal humerus.

Sports after shoulder arthroplasty: a comparative analysis of hemiarthroplasty and reverse total shoulder replacement

BACKGROUND

Traditionally, fewer postoperative sport restrictions are imposed on hemiarthroplasty (HHA) patients on than reverse total shoulder arthroplasty (RTSA) patients. However, functional outcomes have been shown to be superior in RTSA. No direct comparison of RTSA vs HHA has been done on rates of return to sports in patients with glenohumeral arthritis and rotator cuff dysfunction, proximal humeral fractures, or rheumatoid arthritis.

METHODS

This is a retrospective review of consecutive RTSA and HHA patients collected from our institution's shoulder arthroplasty registry. All patients playing sports preoperatively with minimum 1-year follow-up were included. Final follow-up included an additional patient-reported questionnaire with questions regarding physical fitness and sport activities.

RESULTS

The study included 102 RTSA and 71 HHA patients. Average age at surgery was 72.3 years for RTSA compared with 65.6 years for HHA (P < .001). Patients undergoing RTSA had improved visual analog scale scores compared with HHA (-5.6 vs -4.2, P = .007), returned to sports after RTSA at a significantly higher rate (85.9% vs 66.7%, P = .02), and were more likely to be satisfied with their ability to play sports (P = .013). HHA patients were also more likely to have postoperative complaints than RTSA patients (63% vs 29%, P < .0001). No sports-related complications occurred. Female sex, age <70 years, surgery on the dominant extremity, and a preoperative diagnosis of arthritis with rotator cuff dysfunction predicted a higher likelihood of return to sports for patients undergoing RTSA compared with HHA.

CONCLUSIONS

Despite traditional sport restrictions placed on RTSA, patients undergoing RTSA can return to sports at rates higher than those undergoing HHA, with fewer postoperative complaints.

Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: a cost-utility analysis

BACKGROUND

Shoulder hemiarthroplasty (HA) has been the standard treatment for complex proximal humerus fractures in the elderly requiring surgery but not amenable to fixation. Reverse total shoulder arthroplasty (RTSA) has also emerged as a costly albeit highly effective alternative. The purpose of this study was to compare the cost-effectiveness of nonoperative fracture care, HA, and RTSA for complex proximal humerus fractures from the perspective of both U.S. payors and hospitals.

METHODS

A Markov model was constructed for the treatment alternatives. Costs were expressed in 2013 U.S. dollars and effectiveness in quality-adjusted life-years (QALYs). The principal outcome measure was incremental cost-effectiveness ratio (ICER). Sensitivity analyses were performed to evaluate model assumptions.

RESULTS

In the base case, from the payor perspective, RTSA was associated with an ICER of $8100/QALY; HA was eliminated from payor analysis as a cost-ineffective strategy. From the hospital perspective, however, HA was not cost-ineffective and the ICER for HA was $36,700/QALY, with RTSA providing incremental effectiveness at $57,400/QALY. RTSA was the optimal strategy in 61% and 54% of payor and hospital probabilistic sensitivity analyses, respectively. The preferred strategy was dependent on associated QALY gains, primary RTSA cost, and failure rates for RTSA.

CONCLUSIONS

RTSA can be a cost-effective intervention in the surgical treatment of complex proximal humerus fractures. HA can also be a cost-effective intervention, depending on the cost perspective (cost-ineffective for payor but cost-effective for the hospital). This analysis highlights the opportunities for increased cost-sharing strategies to alleviate the cost burden on hospitals.

Surgical Management of Proximal Humeral Fractures: The Emerging Role of Reverse Total Shoulder Arthroplasty

Acute proximal humeral fractures are common injuries in elderly patients. These fractures can lead to significant pain and functional loss. Nonoperative treatment offers high rates of satisfactory function and pain relief in the majority of fractures, particularly in elderly patients. Open reduction and internal fixation, closed reduction and percutaneous pinning, and hemiarthroplasty are used for treating displaced proximal humeral fractures, depending on patient and fracture characteristics. Recently, reverse total shoulder arthroplasty has gained popularity for treatment of complex proximal humeral fractures due to a rapid recovery of active elevation and activities of daily living function. Although complications remain a concern, early results of reverse total shoulder arthroplasty for proximal humeral fractures have been promising. Future comparative outcome studies are needed to define the indications for reverse total shoulder arthroplasty instead of nonoperative and other operative options. Optimal treatment of proximal humeral fractures requires clinical judgment based on fracture characteristics, bone quality, patient factors, and surgeon experience with the array of available techniques. [Orthopedics. 2016; 39(3):e465-e473.].

Four-part fractures treated with a reversed total shoulder prosthesis: Prospective and retrospective multicenter study. Results and complications

INTRODUCTION

The reversed shoulder prosthesis is becoming the gold standard for cases of complex fracture of the proximal humerus after 70 years of age.

MATERIAL AND METHODS

The French Society of Orthopaedic and Traumatology Surgery (SOFCOT) conducted a prospective and retrospective multicenter study to evaluate the results of the reversed shoulder prosthesis implanted in patients with a four-part fracture in nine centers. In the retrospective study (n=41 patients, 78 years of age, 14% ASA grade 3, 21% associated fractures) and in the prospective study (n=32 patients, 79 years of age, 37% ASA grade 3, 21% associated fractures) evaluation by independent surgeons was conducted to measure the QuickDASH score, the Constant score, the SSV (subjective shoulder value), and complications to correlate these measurements with radiological results.

RESULTS

In both studies, use of an autograft (75%) to perform an osteosuture of tuberosities (90%) and no postoperative immobilization (75%) were similar. In the retrospective study at 39 months (range: 24-62 months) of follow-up, the QuickDASH reached 28 (range: 0-59), the Constant scores (raw Constant=57, weighted Constant=83.4%), and SSV 75 (range: 35-100). Complications after the 1st month (7%) were nonunion or ossifications. In the prospective study at 11 months (range: 5-16.5 months) of follow-up, the QuickDASH reached 40 (range: 1-75), the Constant scores 50 (raw Constant) and 74.6% (weighted Constant), and SSV 69 (range: 10-100). Complications after the 1st month (21%) were stiffness and dislocation, with two patients who underwent revision surgery. In both studies, early complications reached 6% (palsy, dislocation).

CONCLUSION

This double (retrospective and prospective) study confirms the good results with a low level of complications of the reversed implant in cases of fracture but with osteosuture of tuberosities.

Functional and radiologic outcomes of uncemented reverse shoulder arthroplasty in proximal humeral fractures: cementing the humeral component is not necessary

BACKGROUND

Our aim was to determine the radiologic and functional outcomes of patients who underwent reverse shoulder arthroplasty (RSA) for proximal humeral fractures and to assess whether the uncemented humeral components put them at risk for early loosening and failure.

METHODS

Thirty-three patients were identified in our hospital database (January 2004-December 2012). Twenty patients were assessed using American Shoulder Elbow Surgeons (ASES) score, Constant Shoulder Score (CSS), and the Oxford Shoulder Score (OSS). Up-to-date shoulder radiographs were evaluated for evidence of radiologic loosening.

RESULTS

The mean follow-up period was 3.0 years (range, 2.5-7.8 years), and the mean age at the time of surgery was 76.5 years (range, 62-87 years). The mean ASES was 75.9 of 100 (range, 55-98.3), with a mean visual analog scale pain score of 2 of 10. The mean OSS was 42.5 of 48 (range, 35-48), and the mean CSS was 54.1 of 100 (range, 32-72). Upon radiographic assessment of the humeral component, 6 patients (30%) had 3 or more lucent zones, and 12 patients (60%) had a lucent zone measuring more than 2 mm in width; however, only 2 patients (10%) had 3 or more lucent zones measuring 2 mm or more in width and were identified as "at risk of loosening." No patients had tilt or subsidence of the humeral prosthesis.

CONCLUSIONS

Our study demonstrated satisfactory functional and radiologic outcomes of patients compared with other studies, suggesting that RSA is a good management option for elderly patients with these fractures. The uncemented nature of the humeral component did not result in early loosening or failure.

Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures

BACKGROUND

Open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and anatomic or reverse total shoulder arthroplasty (TSA/RTSA) are surgical treatment options for proximal humeral fractures (PHFx). Little is known about comparative complication rates. We aimed to determine whether ORIF for PHFx has fewer 30-day complications than HA and TSA/RTSA and to define independent risk factors for 30-day complications.

METHODS

Patients who underwent ORIF, HA, or TSA/RTSA for PHFx between 2006 and 2013 were identified from the National Surgical Quality Improvement Program database. Potential patient and surgical risk factors and 30-day postoperative complications were extracted. Univariate and multivariate analyses were conducted.

RESULTS

We identified 1791 patients (1262 ORIF, 404 HA, and 125 TSA/RTSA). The overall complication rate was 13.0% in ORIF, 22.0% in HA, and 23.2% in TSA/RTSA (P < .001), driven primarily by rates of blood transfusion. Multivariate analyses demonstrated ORIF was an independent protective factor against minor complications (P = .009) and overall complications (P = .028) but not against major complications (P = .351). Risk factors for overall complications included preoperative sepsis (P < .001), higher American Society of Anesthesiologists Physical Status Classification (P < .001), dependent functional status (P = .002), transfusion of at least 5 units in the 72 hours before surgery (P = .002), longer operative time (P = .003), and a history of chronic obstructive pulmonary disease (P = .028).

CONCLUSIONS

After adjusting for patient factors, ORIF for PHFx remains an independent protective factor against overall complications and minor complications compared with HA and TSA/RTSA, primarily due to lower rates of blood transfusion. Patient comorbidities play a larger role than the procedure selected in predicting short-term complications.

Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis

BACKGROUND

We performed a meta-analysis of studies with at least Level IV evidence to compare outcomes between hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures.

METHODS

Three electronic databases (PubMed, Cochrane, and EMBASE) were searched. The quality of each study was investigated, and data on radiographic and functional outcomes were extracted and analyzed.

RESULTS

The analysis included 1 Level I study, 1 Level II study, 3 Level III studies, and 2 Level IV studies. Reverse shoulder arthroplasty was more favorable than hemiarthroplasty in forward elevation (P < .001), abduction (P < .001), tuberosity healing (P = .002), Constant score (P < .001), American Shoulder and Elbow Surgeons score (P < .001), and Disabilities of the Arm, Shoulder and Hand score (P = .001). Only external rotation (P = .85) was not in favor of reverse shoulder arthroplasty.

CONCLUSIONS

The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication.

Reverse shoulder arthroplasty for acute proximal humeral fractures in the geriatric patient: results, health-related quality of life and complication rates

PURPOSE

Reverse shoulder arthroplasty (RSA) in fractures is especially indicated in patients of advanced age, although the influence of age on functional outcomes, health-related quality of life (HRQoL) and complication rate is unknown. We hypothesized that complication rate would decrease in the geriatric population because of their reduced activity, improving the perceived HRQoL.

METHODS

Retrospective study of 42 patients with proximal humeral fractures treated with RSA, divided into two groups: <80 years (<80y)(n = 16) and ≥80 years (≥80y)(n = 26). The assessment tools used were radiological images (functional outcome) with the Constant-Murley score(CMS); disabilities of the arm, shoulder and hand (DASH) score; and HRQoL with the EQ-5D index. Mean follow-up time was 32.6 months.

RESULTS

Mean CMS adjusted for age and sex (R-CMS) was 68 % ± 29 %. Patients in the ≥80y group had a lower total CMS, 33 vs 64 (p = 0.027). Mean active range of motion at 24 months <80y/≥80y was: forward flexion: 126°/110°; abduction: 117°/105°; external rotation: 22°/20°; and internal rotation: L3/sacrum. Mean EQ-VAS was 74 ± 16 in the <80y group, and 63 ± 12.6 in the ≥80y group. Mean DASH was 29.5 ± 9.2. The EQ-5D "self-care" item in the >80y group was the most affected. The "pain/discomfort" item was lower for the two age groups than for the reference population. There were 9.5 % complications: one prosthesis dislocation, one periprosthetic fracture and two surgical wound haematoma.

CONCLUSIONS

Our results indicate that age is a critical factor for RSA success. Lower functional outcomes have been obtained in patients older than 80y, although the EQ-5D results in our sample were similar or even better than the referred population.

LEVEL OF EVIDENCE

Level III.