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

Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis

INTRODUCTION

Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).

METHODS

A systematic search of the literature was undertaken using the Medline®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.

RESULTS

A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.

CONCLUSIONS

This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Trends in Shoulder Arthroplasty in Germany: A 10-Year Epidemiological Analysis of Patients with Primary Osteoarthritis of the Shoulder

Shoulder arthroplasty has significantly gained popularity in orthopedic surgery, driven by progress in prosthesis design and surgical techniques. This study explored the epidemiology of shoulder arthroplasty, analyzing healthcare data from 2012 to 2022 for primary osteoarthritis of the shoulder. The data included patient demographics and types of surgical procedures. Data analysis indicates a higher utilization rate of reverse total shoulder arthroplasty (RTSA; n = 41,251) over total- (TSA; n = 18,679) and hemiarthroplasty (HSA; n = 12,827) for primary shoulder osteoarthritis. Overall, a significant increase in RTSA procedures from n = 2237 (2012) to n = 5415 (2022) was observed, representing more than a two-fold increase of 121.1%. The relative proportion of RTSA among all types of shoulder arthroplasty increased from 39% (2012) to 68.6% (2022), while HSA decreased and TSA essentially remained constant. Age analysis identified the following peaks: RTSA, 77 ± 7 y; HSA, 68 ± 12 y; and TSA, 67 ± 10 y. Among the over 60s, significantly more women were treated with any type of prosthesis, whereas in young patients (45 to 59 y), more men received HSA or TSA. Our study confirms that RTSA has become the preferred choice for elderly patients in Germany, reflecting the prevailing preference despite varying patient ages and conditions, with a noted difference in sex in treatment prevalence.

Reverse Shoulder Arthroplasty in Nonagenarians - NIS-based study of perioperative and postoperative complications

Purpose

Our aim is to investigate the length of stay (LOS), cost of care (COC) and postoperative complications associated with reverse shoulder arthroplasty (RSA) in nonagenarians (people aged 90-99 years old).

Methods

We used the National Inpatient Sample (NIS) database to identify 59,925 patients who underwent RSA between 2016 and 2019, including 555 nonagenarians. We investigated the incidences of various medical and orthopedic postoperative complications in nonagenarians compared to their younger counterparts, as well as compared nonagenarians undergoing elective and non-elective surgery.

Results

Nonagenarians were less likely admitted for elective surgery (69.9% in nonagenarians vs 92.8% in controls, p < 0.001) and were subject to longer LOS (3.5 days in nonagenarians vs 1.89 days in controls, p < 0.001) and greater COC ($91,794.69 US in nonagenarians vs $79,574.12 US in controls, p < 0.001). Nonagenarians had increased incidences of hospital mortality (0.72% in nonagenarians vs 0.06% in controls, p < 0.001), pneumonia (1.44% in nonagenarians vs 0.37% in controls, p < 0.001), blood loss anemia (22.34% in nonagenarians vs 10.12% in controls, p < 0.001), and ARF (6.85% in nonagenarians vs 2.18% in controls, p < 0.001). Nonagenarians undergoing elective RSA had fewer complications than those requiring non-elective RSA.

Conclusion

Nonagenarians undergoing RSA are subject to increased LOS, COC, and postoperative complications. Despite this, we feel that the associated complications can be deemed acceptable and that with adequate preparation, the benefits of a successful RSA may outweigh the associated complications in elderly patients. This is important to aid clinicians and patients in making informed decisions for patient care and resource allocation, as well as highlights room for improvement in costs and hospital stay, as well as sheds light on persistent health disparities in orthopedic surgery.

Level of evidence

IV.

Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures - a propensity score matched comparison

BACKGROUND

Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF).

METHODS

All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared.

RESULTS

Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant.

CONCLUSION

rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures

BACKGROUND

Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context.

METHODS

A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review.

RESULTS

Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study.

CONCLUSION

Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years

BACKGROUND

Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear.

QUESTIONS/PURPOSES

(1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?

METHODS

Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only.

RESULTS

Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35 o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27 o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07).

CONCLUSION

In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Functional outcome and CEUS-assessed deltoid muscle vitality after fracture-specific versus standard prosthetic design in reverse shoulder arthroplasty for trauma

Functional outcome after reverse-shoulder-arthroplasty (RSA) in proximal humerus fractures (PHF) depends on deltoid muscle integrity and successful reattachment of the tuberosities for best possible recovery of rotator-cuff function. In this monocentric, prospective, randomized, controlled trial we investigated whether a reverse-fracture-prosthesis (RFP) with a metaphyseal fenestrated stem achieved superior shoulder and muscle function compared to a common reverse-prosthesis (RP) design for patients with PHF. Our hypothesis was that patients with RFP may achieve a superior healing rate of the greater tuberosity (GT) compared to patients receiving RP, which translates to significantly higher clinical outcome and functional scores as well as differences in deltoid muscle microperfusion. Forty-four patients with PHF were randomized preoperatively to one of the prosthesis types in RSA between 2018 and 2020 (22 with RFP and 22 with RP) and prospectively assessed 6 months after surgery. We assessed osteointegration of the GT with radiographs 1 day and 6 months postoperatively and examined shoulder function and patient satisfaction by using established shoulder scores. A contrast-enhanced ultrasound (CEUS) examination of both shoulders was performed to quantify intramuscular blood flow and evaluate vitality of the deltoid muscle. None of the functional and psychosocial scores or radiographs and ultrasound examinations showed significant differences between the RSA designs. The constant-Murley score (p = 0.384) and active anterior-elevation-abduction, and external rotation were comparable between the RFP and RP group. Similar healing rates of the GT were observed (p = 0.655). CEUS-assessed deltoid microperfusion revealed equivalent muscle vitality for both groups (p = 0.312). Level of evidence: Level II; Randomized Controlled Trial; Treatment Study. Clinical significance: The radiographic evaluation for the investigation of the GT healing rate indicates that the proclaimed benefits of the fracture prosthesis with fenestration design might not be as great as expected.

Humeral and Glenoid Version in Reverse Total Shoulder Arthroplasty: A Systematic Review

There is increasing interest in reverse total shoulder arthroplasty (RTSA) as a reliable treatment for arthritic, rotator cuff deficient shoulders. Humeral and glenoid version are controversial parameters that can influence internal and external rotation, muscular forces, and implant stability as outcomes of RTSA. The aim of this study was to obtain an overview of the current knowledge on the effect of both humeral component version and glenoid component version and give recommendations on their most optimal degree for RTSA. A comprehensive quantitative review of the published literature on the effect of humeral version and glenoid version in RTSA was performed, to identify its influence on the range of movement, muscle forces, and intrinsic stability of the reverse prosthesis. Eleven studies were included: nine were biomechanical studies, one was a clinical-radiographic study, and one was an implant design consideration. Anterior stability can be improved by implanting the humeral component in neutral or with some anteversion. Glenoid component retroversion has been proven to reduce the likelihood of subluxation, while increasing ER and ROM at the same time. The study was conducted considering 5° anteversion; neutral; and 5°, 10°, and 20° retroversion of the glenoid component. Although a final opinion has not been yet expressed on the matter, the general consensus tends to agree on restoring 0° to 20° of retroversion of the humeral and glenoid component to yield the best outcomes.

Shoulder replacement: an epidemiological nationwide study from 2009 to 2019

Background

Shoulder replacement (SR) constitutes the gold standard treatment for severe shoulder diseases, including osteoarthritis, rheumatoid arthritis, complex fractures, avascular necrosis and rotator cuff arthropathy. Although several countries have national registries, there is a lack of epidemiological data on SR. Sharing national statistics and correlating those to other countries could be helpful to compare outcomes and costs internationally. This paper aims to evaluate the trend of hospitalizations for SR (both first implants and revisions of anatomical and reverse prosthesis) in Italy from 2009 to 2019, based on the National Hospital Discharge Reports (S.D.O) provided by the Italian National Health Service (INHS). Moreover, the economic impact on the healthcare system of SR and SR revisions was assessed, providing a statistical prediction for the next ten years.

Methods

The data used in this paper were about patients who underwent Total Shoulder Replacement (TSR), Shoulder Hemiarthroplasty (SH) or Revision of shoulder joint replacement (RSR) from 2009 to 2019 in Italy. Information about patients was anonymous and included age, sex, days of hospitalization, procedures and diagnoses codes.

Results

From 2009 to 2019, 73,046 TSR and SH were performed in adult Italian residents, with a cumulative incidence of 13.6 cases per 100,000 adult Italian residents. While, 2,129 revisions of shoulder replacement were performed, with a cumulative incidence of 0.4 cases per 100,000 residents. Overall, females represented the majority of the cases (72.4% of patients who underwent TSR or SH and 59.1% of patients who underwent RSR). From 2009 to 2019, has been assessed an overall cost of 625,638,990€ for TSR or SH procedures in Italy. While, an overall cost of 9,855,141€ for RSR procedures in Italy was calculated.

Conclusions

The incidence of SR and RSR is expected to increase in the following years, constituting a burden for the healthcare systems. Overall, in Italy, the females represented the majority of patients. Further prospective studies on this topic in different countries can be con-ducted to make comparisons.

Shoulder arthroplasty for proximal humeral fracture treatment: a retrospective functional outcome analysis

PURPOSE

Following proximal humeral fractures hemiarthroplasty (HA) or reversed total shoulder arthroplasty (rTSA) are performed if osteosynthesis or conservative treatment is not possible. HA has been reported to result in decreased functional outcomes compared with rTSA. Secondary shoulder arthroplasty, performed after a different initial treatment, has also been associated with inferior outcomes.

METHODS

Patients recieving a shoulder arthroplasty related to a proximal humeral fracture from 2010 to 2019 were included. A retrospective analysis of functional outcomes was performed using QuickDASH and subjective shoulder value (SSV).

RESULTS

The mean [standard deviation (SD)] follow-up time among the 82 included patients was 48 (28) months. The mean age was 70 (10) years. The mean age for HA was significantly different from rTSA [57 (9) and 72 (21) years; p < .001]. The mean QuickDASH score for primary arthroplasty was 11 (2) versus 12 (16) for secondary arthroplasty (p = .313). The mean SSV for primary arthroplasty was 84 (22) versus 82 (17) for secondary arthroplasty (p = .578). The mean QuickDASH score for HA was 24 (36) versus 9 (15) for rTSA (p = .346). The mean SSV for HA was 70 (34) versus 86 (17) for rTSA (p = .578).

CONCLUSION

Functional outcomes after fracture-related shoulder arthroplasty were excellent in an older population, even when performed secondarily after failed primary osteosynthesis or conservative treatment. No significant differences in shoulder function were identified between rTSA and HA, likely due to restrictive indications for HA.

Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review

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The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population.

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Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence.

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RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve.

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RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures.

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RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Comparison of 30-day complications between reverse shoulder arthroplasty and open reduction internal fixation for the treatment of proximal humerus fractures

PURPOSE

While the use of open reduction internal fixation (ORIF) has remained stable over the last decade, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs). This study sought to compare the complication profiles of RTSA to ORIF in a large, validated, retrospective cohort.

METHODS

Patients who underwent surgical treatment for PHFs with RTSA or ORIF were identified in a national database (NSQIP) using CPT and ICD codes. Demographics and comorbidities were identified for each cohort of patients. Thirty-day complications were analyzed with univariate and multivariate analyses using Chi-square, Fischer's exact and analysis of variance testing.

RESULTS

The total number of patients included in this study was 2157.522 (24.2%) underwent RTSA and 1635 (75.8%) underwent ORIF. Patients undergoing RTSA were older with an average age of 73.52 years compared with 63.84 years in those undergoing ORIF (p < 0.001). Patients with RTSA were more likely to experience any complications (p < 0.001), pulmonary complications (p = 0.029), extended length of stay > 3 days (p < 0.001), and perioperative transfusion requirement (p < 0.001) after univariate analysis. After controlling for demographic differences, the only statistically significant complication was perioperative transfusion requirement (OR 1.383).

CONCLUSION

After controlling for demographic variables and comorbidities, RTSA placed patients at increased risk for perioperative blood transfusion. Patients undergoing RTSA should be counseled prior to surgery regarding the risk for transfusion and potentially optimized medically through multidisciplinary care if the surgeon elects to proceed with RTSA versus ORIF for the treatment of PHFs.

Outcomes of Reverse Total Shoulder Arthroplasties Performed for Proximal Humeral Fractures Versus Elective Etiologies

BACKGROUND

Reverse Total Shoulder Arthroplasty is commonly performed for elective indications, such as cuff tear arthropathies, salvage arthropathies and tumours with excellent outcomes. However, its use in treating acute conditions such as 3- and 4-part proximal humeral fractures in the elderly has been more controversial. The aim of our study is to directly compare the short-term intra-operative and post-operative outcomes of RTSA for traumatic proximal humeral fractures as compared to elective shoulder arthroplasty.

METHODS

We retrospectively identified 78 consecutive patients who had undergone RTSA from 2009 to 2018 at a tertiary hospital. These patients were classified by etiology as either elective or trauma cases. Comparative analysis of the baseline demographics, as well as post-operative surgical, functional and range-of-movement outcomes between the two groups was performed.

RESULTS

57 Patients made up the elective cohort and 14 patients made up the trauma cohort. The elective cohort was significantly older compared to the traumatic fracture cohort (73.2 vs 78.6, p = 0.026). No significant differences were observed when comparing post-operative surgical outcomes. At 6 months, the elective cohort demonstrated greater forward flexion (105.8° vs 127.2°, p = 0.041), as well as higher SF-36 PCS (27.85 vs 43.99, p = 0.018) and ASES scores (35.5 vs 76.31, p = 0.009). However, these differences resolved by 1-year post-op and no significant differences were noted comparing functional and range-of-movement outcomes at 1-year post-op.

CONCLUSIONS

Our study suggests that the application of reverse total shoulder arthroplasty in the management of traumatic humeral fractures may produce similarly favourable 1-year outcomes to that performed for elective etiologies.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-022-00625-4.

Management options for proximal humerus fractures - A systematic review & network meta-analysis of randomized control trials

AIMS

The purpose of this study is to systematically review the randomized controlled trials on the various treatment options that can be utilized in the management of displaced proximal humerus fractures.

MATERIALS & METHODS

Based on the PRISMA guidelines, three independent reviewers performed a systematic review of the literature. Randomized control trials (RCTs) focusing on the outcomes of the following interventions in the management of PHFs were considered for inclusion; (1) non-operative or conservative (NOC) management, (2) open reduction and internal fixation (ORIF), (3) intra-medullary nailing (IMN), (4) shoulder hemi-arthroplasty (HA), and (5) reverse shoulder arthroplasty (RSA). Network meta-analyses were performed using R and studies were ranked according to their P-score.

RESULTS

Our study included 13 RCTs. RSA had improvements in abduction, constant score, flexion, as well as lowest rates of malunion and osteonecrosis when compared to other management modalities (P-Score = 0.9786, P-Score = 0.9998, P-Score = 0.9909, P-Score = 0.9590 and P-Score = 0.8042 respectively). HA was found to have improvements in health-related quality of life scores when compared to other management modalities (P-Score = 0.9672). ORIF had the highest improvement in quick disability of arm, shoulder and hand scores and visual analogue scale scores (P-Score = 0.8209 and P-Score = 0.7155 respectively). NOC was found to have the lowest rate of conversion to surgical intervention, with RSA having the lowest rate of surgical interventions (P-Score = 0.9186 and P-Score = 0.7497 respectively).

DISCUSSION & CONCLUSION

RSA offers satisfactory improvements in clinical and functional outcomes when compared to other non-operative and operative treatment options in the management of carefully selected proximal humerus fractures, with a minimal revision rate when compared to other surgical management modalities.

LEVEL OF EVIDENCE

I - Systematic Review & Meta-Analysis of Randomized Control Trials.

Comparison of Early Range of Motion in Reverse Shoulder Arthroplasty Based on Indication: A Single Center Retrospective Review

Background

Reverse shoulder arthroplasty (RSA) is commonly used in the treatment of rotator cuff arthropathy. Indications for RSA have expanded to include complex proximal humerus fractures. Studies directly comparing outcomes between traumatic and traditional elective indications are limited. The purpose of this study was to compare early active range of motion (aROM) within the first two years postoperatively between traumatic and non-traumatic primary RSA, as well as compare ASES scores, and patient satisfaction at final follow-up.

Methods

A retrospective analysis was conducted of all RSA performed by a single surgeon between January 2000 and December 2018. Patients were grouped by indication into traumatic and non-traumatic elective groups. Demographics, surgical data, and routine aROM data were collected. aROM was compared at 3, 6, 12, and 24 months. American Shoulder and Elbow Surgeons (ASES) score and patient satisfaction were determined at the time of this investigation.

Results

367 RSA procedures were performed by the senior author during the study period, 88 for fracture (24%), and 279 for non-traumatic elective indications (76%). Forward elevation and external rotation were inferior in the fracture group at all time points in the first two years. Internal rotation was equivalent throughout the first two years. Final ASES scores were 77.6 versus 83.5 in the fracture and non-fracture groups, respectively (p = .33).

Conclusion

Patients undergoing RSA for fracture had statistically significant inferior aROM in forward elevation and external rotation throughout the first two years. Despite having inferior aROM, ASES scores and patient satisfaction at final follow-up were statistically equivalent.

Level of Evidence

Level III; Retrospective Cohort Comparision; Prognosis Study

Clinical outcomes of reverse total shoulder arthroplasty for elective indications versus acute 3- and 4-part proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has continued to increase in clinical utility and popularity as an effective treatment for cuff tear arthropathy (CTA), irreparable rotator cuff tears (RCTs), osteoarthritis, and acute 3- and 4-part proximal humeral fractures. Performing RTSA for acute proximal humeral fractures presents the unique challenges of tuberosity management, bone loss, and instability compared with elective indications such as CTA or irreparable RCTs. The purpose of this study was to compare the clinical outcomes, active range of motion (ROM), radiographic outcomes, and complications between patients undergoing elective RTSA (RTSA-E) and those undergoing RTSA for fracture (RTSA-F).

METHODS

A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We queried 3 electronic databases (Embase, Cochrane, and PubMed) using the search term "reverse" AND "shoulder" AND "arthroplasty." Studies investigating the clinical outcomes of RTSA for traumatic and/or elective indications were included. Studies were excluded if they included RTSA performed for fracture sequelae, inflammatory arthritis, post-traumatic osteoarthritis, or avascular necrosis. Data collected included patient demographic characteristics, subjective outcome measurements, ROM, and complications. The pooled means and proportions along with their 95% confidence intervals were generated by a random-effects model that incorporated the between-study variations in weighting.

RESULTS

A total of 134 studies (11,651 shoulders) investigating the clinical outcomes of RTSA-E patients and 66 studies (3117 shoulders) investigating RTSA-F patients were included in this systematic review. Analysis of patient-reported outcomes demonstrated that RTSA-F patients experienced significantly lower Constant scores than RTSA-E patients; however, relative Constant scores, Simple Shoulder Test scores, Disabilities of the Arm, Shoulder and Hand scores, American Shoulder and Elbow Surgeons scores, and visual analog scale pain scores were similar. RTSA-F patients also had significantly lower forward elevation, abduction, and external rotation. RTSA-F patients experienced tuberosity complications at a significantly higher rate than RTSA-E patients (25.9% vs. 4.1%). There was no significant difference between the 2 groups in terms of other complications such as heterotopic ossification, radiographic loosening, revision, nerve injury, postoperative stiffness, infection, dislocation, and component loosening.

DISCUSSION

RTSA performed for acute 3- and 4-part proximal humeral fractures yields overall worse clinical outcomes and active ROM compared with RTSA performed for elective indications including CTA, massive irreparable RCTs, and osteoarthritis with deformity. Tuberosity healing may be a major contributing factor to the difference in clinical outcomes. In the setting of RTSA-F, patient and surgeon expectations may need to be tempered and appropriate measures undertaken to optimize tuberosity healing.

Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for the Treatment of Proximal Humerus Fractures: A Model-Based Cost-Effectiveness Analysis

INTRODUCTION

Compared with hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA) may provide greater cost and health-related benefits for patients with complex three- and four-part proximal humeral fractures. This study set out to compare RTSA versus HA for the incremental cost per incremental improvement in quality adjusted life years (QALYs) for a hypothetical cohort of patients with proximal humerus fractures.

METHODS

Parameters and characteristics for a hypothetical cohort of elderly patients with proximal humerus fractures were collected through the literature. A cohort-level Markov decision model was constructed. Incremental cost-effectiveness ratios representing the difference in cost divided by the difference in QALYs were calculated, and scenario, one-way, and probabilistic analysis were conducted.

RESULTS

RTSA was associated with lower cost and greater effectiveness compared with HA. The predicted cost difference corresponded to a saving of $99,626 per 100 individuals treated, and the predicted difference in QALY was 16.8 per 100 individuals treated. Results were sensitive to the discount rate, the health-related quality of life assigned to health states, and the cost of the surgical procedures. In probabilistic analysis, 77.1% of iterations were cost-effective at a threshold willingness-to-pay for a QALY of $100,000 US dollars.

DISCUSSION

Findings suggest that RTSA may be a cost-effective alternative to HA for treating elderly patients requiring surgery for proximal humerus fractures.

DATA AVAILABILITY

The model and corresponding code are available on request to the corresponding author.

LEVEL OF EVIDENCE USING THE JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS GUIDANCE

Level III.

Reverse or Hemi Shoulder Arthroplasty in Proximal Humerus Fractures: A Single-Blinded Prospective Multicenter Randomized Clinical Trial

OBJECTIVES

To compare outcomes between hemiarthroplasty (HA) and reversed shoulder arthroplasty (RSA) as a treatment for dislocated 3-part and 4-part proximal humerus fractures in the elderly population.

DESIGN

Prospective multicenter randomized controlled trial.

SETTING

Three Level-1 trauma centers.

PATIENTS/PARTICIPANTS

This study included 31 patients of which 14 were randomized into the HA group and 17 into the RSA group.

INTERVENTION

Patients randomized to the HA group were treated with a cemented-stem Aequalis-fracture HA and patients randomized to the RSA group with a cemented-stem Aequalis-fracture RSA.

MAIN OUTCOME MEASUREMENTS

Primary outcomes consisted of range of motion and constant score. Secondary outcomes were the visual analog scale for pain, DASH score, SF-12 scores, and radiographic outcomes.

RESULTS

After 6 and 12 months of follow-up, RSA showed a significant higher anterior elevation (105 degrees vs. 80 degrees, P = 0.002 and 110 degrees vs. 90 degrees, P = 0.02, respectively) and constant score (60 vs. 41, P = 0.01 and 51 vs. 32, P = 0.05, respectively) compared with HA. There were no significant differences in external and internal rotation. Also, visual analog scale pain, DASH scores, SF-12 scores, and radiological healing of the tuberosities and heterotopic ossification did not show any significant differences between groups.

CONCLUSION

RSA showed significant superior functional outcomes for anterior elevation and constant score compared with HA for dislocated 3-part and 4-part proximal humerus fractures after short-term follow-up.

LEVEL OF EVIDENCE

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

Clinical effect of using MultiLoc® nails to treat four-part proximal humeral fractures

Objective

This study was performed to evaluate the clinical effect of MultiLoc® nails (DePuy Synthes, Raynham, MA, USA) on the treatment of four-part proximal humeral fractures (PHFs).

Methods

From January 2014 to January 2018, 32 patients with four-part PHFs were treated with intramedullary MultiLoc® nails in our hospital. The operation time, bleeding volume, postoperative X-ray findings, and fracture healing status were recorded and analyzed. At the end of follow-up, the clinical outcome was evaluated based on the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant–Murley score (CMS), and occurrence of any complications.

Results

Among all patients, the average operation time was 124.5 minutes (range, 91–152 minutes), the average amount of bleeding was 90 mL (range, 55–150 mL), and the fracture healing rate was 100%. At the end of follow-up, the mean VAS score was 1.6 ± 0.4, mean ASES score was 84.4 ± 6.3, and mean CMS was 70.3 ± 6.1; no serious complications had occurred; and the patients exhibited good recovery of shoulder function.

Conclusions

MultiLoc nails® can be applied to the treatment of four-part PHFs. This surgical fixation method has no obvious complications and helps to restore shoulder function.

Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review

BACKGROUND

Proximal humeral fractures are difficult injuries to treat and obtain satisfactory outcomes. For those treated with arthroplasty, humeral fracture stems have been popular due to better ability for reduction and fixation of tuberosities. This study aims to investigate the outcomes of fracture stems in shoulder arthroplasty for proximal humeral fracture and the comparison of outcomes between fracture vs. nonfracture stems.

METHODS

A meta-analysis was conducted with a multidatabase search (PubMed, OVID, EMBASE, Medline) according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines on May 19, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed.

FINDINGS

Eleven studies were included for analysis, including 383 hemiarthroplasties (HA) (294 fracture stems, 89 nonfracture stems) and 358 reverse total shoulder arthroplasties (RTSA) (309 fracture stems, 49 nonfracture stems). At the final follow-up, meta-analysis shows favorable overall ASES score in all fracture stem prosthesis (mean = 74.0, 95% confidence interval [CI]: 69.3-78.7), Constant-Murley score (mean = 67.2, 95% CI: 61.6-72.8), external rotation (mean difference [MD] = 7°, 95% CI: 3°-10°, P < .001), and forward flexion (MD = 17°, 95% CI: 10°-25°, P < .001). Pooled proportion (PP) of greater tuberosity healing (PP = 0.786, 95% CI: 0.686-0.886) was high, whereas all-cause revisions (PP = 0.034, 95% CI: 0.018-0.061) remained low. With the exception of RTSA scapular notching (PP = 0.109, 95% CI: 0.020-0.343), other complication metrics had PP of ≤0.023. In the 4 studies comparing fracture (138 HA, 54 RTSA) vs. nonfracture stems (89 HA, 49 RTSA), fracture stems had statistically significant better American Shoulder and Elbow Surgeons scores (MD = 14.29, 95% CI: 8.18-20.41, P < .001), external rotation (MD = 6°, 95% CI: 2°-9°, P = .003), forward flexion (MD = 16°, 95% CI: 7°-24°, P < .001), and greater tuberosity healing (odds ratio = 2.20, 95% CI: 1.28-3.77, P = .004). There was no statistically significant difference in complications.

CONCLUSION

Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. The use of fracture stems is also associated with greater chance of tuberosity healing compared with nonfracture stems. There is increasing evidence to suggest the superiority of fracture stems over nonfracture stems in clinical outcomes, while maintaining similar complication rates.

Does reverse total shoulder arthroplasty for proximal humeral fracture portend poorer outcomes than for elective indications?

BACKGROUND

The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA.

METHODS

A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups.

RESULTS

In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months.

CONCLUSION

Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.

Treatment of Complex Proximal Humeral Fractures in the Elderly with Reverse Shoulder Arthroplasty

OBJECTIVE

To assess the short-term efficacy of reverse shoulder arthroplasty in the treatment of complex proximal humeral fractures in the elderly.

METHODS

Forty-three elderly patients treated operatively for complex proximal humeral fractures with reverse shoulder arthroplasty from July 2017 to January 2019 were retrospectively reviewed. To be specific, 12 males and 31 females were reviewed with an average age of 72.0 years (range, 66-78 years). All fractures were attributed to trauma and treated for 8.0 days on average (range, 6-11 days). As suggested from Neer classification, 21 cases (48.8%, 21/43) were three-part fractures, and 22 (51.2%, 22/43) were four-part fractures. To assess the postoperative efficacy, Visual Analog Scale (VAS), American Society of Shoulder and Elbow Surgery Shoulder Joint Score (ASES), Constant-Murley score and radiological examination were adopted. The Neer three-part fracture group and the Neer four-part fracture group were compared.

RESULTS

There was no significant difference in age, gender, operation time, and follow-up period between Neer three-part fracture group and Neer four-part fracture group. All operations were successfully performed, and the average operation time was 120-170 min, with an average of 141.3 min. Besides, the mean blood loss was 407.0 mL (250-700 mL), and the average intraoperative blood transfusion reached 446.5 mL (400-800 mL). All patients received the follow-up for 6 to 16 months, that is for 10.9 months on average. All patients were discharged in 7 days after operation, and no wound-related complications were identified. In 8 weeks, the greater and lesser tuberosities of all patients healed completely. During the last follow-up, no loosening or dislocation of prosthesis was detected, and the forward elevation of 133.0 (100°- 165°), the external rotation of 29.5° (20°-35°), the internal rotation of 46.7°(30°-60°), the VAS score of 0.8(0-3), the ASES score of 89.1(78.8-100.0) were achieved. Constant-Murley score reached 88.7 (range, 70-98). There was no significant difference between Neer three-part fracture group and Neer four-part fracture group (P > 0.05). A 71-year-old patient developed the symptoms of axillary nerve injury after operation; he recovered completely at 6 weeks after the operation, which had not adversely affected the functional rehabilitation exercise or the stability of the prosthesis. At the follow-up, no other complications (e.g., infection, acromial stress fracture, and scapular notching) were identified in all patients.

CONCLUSION

The short-term efficacy of one-stage reverse shoulder arthroplasty to treat complex proximal humeral fractures in the elderly is satisfactory.

Outcome measures reported for the management of proximal humeral fractures: a systematic review

BACKGROUND

The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.

METHODS

A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.

RESULTS

Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.

CONCLUSION

Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

How to improve the outcomes of surgically treated proximal humeral osteoporotic fractures? A narrative review

Proximal humeral fractures (PHF) are the third most common non-vertebral fragility fractures after hip and distal radius. It still controversial which treatment might be more appropriate, and surgically treated outcomes depends also on an appropriate technique. In order to clarify surgical indications, tips and pitfall a narrative review was conducted. Pinning, external fixation, plating and internal fixators has each one its advantages and disadvantages. During the procedure an appropriate use of the fixation device and handling of the soft tissue might be associated with better outcomes. Calcar comminution, varus angulation, medial dislocation of the shaft, fracture-dislocation are factors that could lead to choose a replacement. Hemiarthroplasty and reverse total shoulder arthroplasty are the most common prosthesis used in PHF. The restoration of humeral length and tuberosities might lead to an improvement in clinical outcomes and prosthesis survivorship.

Conjoint tendon release for persistent anterior shoulder pain following reverse total shoulder arthroplasty

Background

Persistent anterior shoulder pain is an under-reported complication after reverse total shoulder arthroplasty (RTSA). The purpose of this study was to determine the effectiveness of open conjoint tendon release in patients with anterior shoulder pain due to conjoint tendinitis after RTSA.

Methods

Open conjoint tendon release was performed by the senior author from June 2014 to November 2018 in patients with persistent anterior shoulder pain after RTSA. Patients were evaluated preoperatively and at a minimum of 1 year postoperatively by phone interview with patient-reported outcome scores including a visual analog scale score for pain and the American Shoulder and Elbow Surgeons score.

Results

We evaluated 11 of 12 patients (92% follow-up) at a minimum of 1 year (average, 27 ± 11 months) after conjoint tendon release. American Shoulder and Elbow Surgeons and visual analog scale pain scores improved from 29.0 ± 22.1 and 7.3 ± 2.0, respectively, preoperatively to 58.2 ± 30.6 and 3.1 ± 3.5, respectively, postoperatively, after open conjoint tendon release (P = .02 and P = .003, respectively). Of the patients, 45% (5 of 11) reported improvement but with some coracoid pain after the release whereas 55% (6 of 11) reported no coracoid pain after the release. No complications occurred as a result of the release, and no patients required reoperation.

Conclusion

Our results suggest that conjoint tendinitis may be a cause of persistent postoperative anterior shoulder pain after RTSA and open conjoint tendon release is a successful treatment.

Risk Factors for Severe Proximal Humerus Fracture and Correlation Between Deltoid Tuberosity Index and Bone Mineral Density

Introduction:

The aims of this study were to investigate (1) whether demographic factors would be risk factors for severe proximal humerus fracture (PHF), (2) relationship of radiological parameters with bone mineral density (BMD), deltoid tuberosity index (DTI), or severe PHF, and (3) correlation between DTI and BMD.

Methods:

We conducted a cross-sectional study based on radiographs and medical records taken during admission or the visit to the orthopedic clinic. We reviewed consecutive 100 adult patients who were diagnosed with PHF in our hospital from March 2014 to December 2016. Three- and 4-part fractures were regarded as severe PHFs. Univariable and multivariable logistic regression analyses were performed to evaluate risk factors for severe PHF. Also, we investigated the correlation between BMD and DTI using the additional BMD data of the patients who underwent shoulder surgeries.

Results:

This study included 62 nonsevere PHFs and 38 severe PHFs. There were 30 male and 70 female patients with a mean age of 66.4 ± 16.4 years. Mean T score of BMD was −2.5 ± 0.9 at the time of injury. Logistic regression analyses showed that age (odds ratio: 1.044, range: 1.011-1.079, P = .009) and sex (odds ratio of females: 3.763, range: 1.236-11.459, P = .020) were related to severe PHF. The group satisfying the radiological parameter criteria had significantly higher rates of severe PHF. The correlation coefficient (r) between DTI and T score was 0.555 (P < .001).

Discussion and Conclusion:

Older age and female were the independent risk factors for severe PHF. Conversely, BMD and other medical comorbidities were not risk factors for severe PHF. Deltoid tuberosity index showed significantly high intraclass correlation coefficient and a strong correlation with the T score of BMD. Therefore, DTI may be useful for screening osteoporosis in PHF patients.

Level of Evidence:

Level IV, Cross-sectional study.

Antibiotic prophylaxis in primary and revision shoulder replacement: a systematic review

Background

One of the most common bacteria responsible for most Periprosthetic joint infection (PJI) is Propionibacterium acnes. Even though the rate of infections in patients undergoing total shoulder arthroplasty is increasing, effective diagnostic tests and the precautions taken during the surgery are not yet adequate. This systematic review aims to evaluate the effectiveness of antimicrobial prophylaxis in PJI in shoulder replacement and to provide health workers with the best approach to the use of antimicrobial agents based on currently available clinical evidence.

Methods

a systematic review of the literature was carried out in accordance with the PRISMA Statement. Studies concerning the effectiveness of antimicrobial prophylaxis in the prevention of PJI in patients undergoing shoulder replacement were included.

Results

Seven studies were included in the final analysis because they were considered valid. A total of 3272 patients underwent a surgical procedure, most of which were males. The male population has a greater presence of hair, therefore a greater risk of P. acnes. in surface cultures. Patients were assessed at an average follow-up period of 20 months ranging from 9 weeks to 53 months.

Conclusion

The optimal perioperative antimicrobial regimen is controversial. The clinical guidelines recommend the use of only one antibiotic as prophylaxis but considering the increase in the rates of antibiotic-resistant infections, the question arises whether antibiotic prophylaxis should be extended for adequate coverage. Shoulder arthroplasty performed on the male population must be carefully checked after surgery for the possible presence of P. Acnes.

Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty

INTRODUCTION

Osteoporosis is a widespread and growing medical condition, with significant orthopaedic implications. However, the effect of osteoporosis on outcomes after total shoulder arthroplasty (TSA) is not well understood. The goal of the present study was to characterize the incidence of osteoporosis in patients undergoing shoulder arthroplasty and to examine whether patients with osteoporosis undergoing anatomic and reverse TSA are at an increased risk of prosthetic-related complications.

METHODS

Complication rates were calculated for patients with osteoporosis who underwent anatomic and reverse TSA as separate cohorts within 2 years of surgery including loosening/osteolysis, periprosthetic fracture, periprosthetic dislocation, and revision shoulder arthroplasty and compared using a multivariable logistic regression analysis to control for patient demographics and comorbidities during comparisons, including the indication for reverse TSA.

RESULTS

The prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients. Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls.

DISCUSSION

A significant number of patients undergoing both anatomic and reverse TSA have a concurrent diagnosis of osteoporosis. Osteoporosis represents a significant independent risk factor for periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery, regardless of the type of implant. Patients with osteoporosis should be counseled on their increased risk of complications after shoulder arthroplasty.

Non-fracture stem vs fracture stem of reverse total shoulder arthroplasty in complex proximal humeral fracture of asian elderly

PURPOSE

Fracture stem of the reverse total shoulder arthroplasty (RTSA) was designed for better tuberosity bone healing for the proximal bone defect of complex proximal humeral fractures (PHF). Our purpose was to compare the clinical and radiological outcomes of patients using fracture stem vs non-fracture (conventional) stem of RTSA in complex PHF of elderly patients.

METHODS

Between 2008 March and 2017 June, 48 patients who had undergone an RTSA with non-fracture or fracture stem for complex PHF with a minimum 18 months of follow-up were evaluated. Finally, total 45 patients with a mean age of 80 ± 7 years (65-92 years) were enrolled because three patients were excluded due to age related mortality. We divided them into two groups: 25 patients using non-fracture stem (non-fracture stem group) in the early period of this study, and consecutive 20 patients using fracture stem (fracture stem group) in the later period. Between two groups, we compared clinical and radiologic outcomes such as tuberosity failure, heterotopic ossification (HO), dislocation, acromion fracture, notching, loosening and periprosthetic fracture.

RESULTS

In all patients, clinical outcomes were improved significantly and tuberosity failure was found in 62% (28/45). Between two groups, there were no statistically significant differences on clinical outcomes and radiologic outcomes except UCLA score. As complications, two humeral stem revision was performed due to tuberosity failure related HO and stem loosening with subsequent periprosthetic fracture in non-fracture stem group.

CONCLUSIONS

Compared to non-fracture stem, fracture stem usage of RTSA in complex PHF of elderly patients has no significant different impact on clinical and radiological outcomes. However, tuberosity failure related secondary HO of non-fracture stem might be responsible for stem loosening and periprosthetic fracture in the RTSA for complex PHF of elderly patients.

LEVEL OF EVIDENCE

Level IV, case series study.

Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial

BACKGROUND

Proximal humeral fractures (PHFs) are among the most common fractures in elderly patients, but there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for their management. To date, no RCT has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for 3- or 4-part PHFs in elderly patients.

METHODS

This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3- and 4-part PHFs, treated by either RSA or nonoperative treatment. Secondary outcome measures included Disabilities of the Arm, Shoulder and Hand, visual analog scale (VAS), Short Form 12 (SF-12), EuroQol 5 Dimensions, and EQ-VAS scores.

RESULTS

We analyzed 30 nonoperative and 29 RSA patients with mean ages of 85 years and 82 years, respectively. No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes at 12 months' follow-up except the VAS pain score. The Constant scores were 55.7 in the nonoperative group and 61.7 in the RSA group (P = .071); the Disabilities of the Arm, Shoulder and Hand scores were 29 and 21, respectively (P = .075); the VAS scores were 1.6 and 0.9, respectively (P = .011); the physical SF-12 scores were 36 and 37, respectively (P = .709); the mental SF-12 scores were 43 and 42, respectively (P = .625); the EuroQol 5 Dimensions scores were 0.89 and 0.92, respectively (P = .319); and the EQ-VAS scores were 65 and 67, respectively (P = .604).

CONCLUSIONS

This study yields important evidence for the treatment of complex PHFs in elderly patients suggesting minimal benefits of RSA over nonoperative treatment for displaced 3- and 4-part PHFs. At short-term follow-up, the main advantage of RSA appeared to be less pain perception.

Treatment of cephalotuberosity fractures in elderly patients treated by reverse shoulder prosthesis: a study of functional results in relation to deltoid tension

INTRODUCTION

The treatment of proximal humerus fractures is a therapeutic challenge in the elderly as the functional demands of these patients are high. We postulated that there may be a relationship between functional results and deltoid tension when these fractures are treated with a reverse prosthesis. This study was performed to determine the optimal tension of the deltoid. The primary outcome was the constant score in relation to humeral length at the final follow-up.

MATERIALS AND METHODS

Our retrospective cohort consisted of 45 patients treated with a reverse fracture prosthesis during the period from January 2010 to July 2017. The fractures were all classified as Neer III or IV, 91% of our patients were women and the average age was 82 years.

RESULTS

Constant score and antepulsion were improved with humeral elongation between 10 and 25 mm (p < 0.02 and p < 0.05, respectively). External rotation was improved with humeral elongation (p < 0.03).

CONCLUSION

Tuberosity reinsertion improves mobility in patients treated surgically for a reverse fracture prosthesis. The recovery of anatomical retroversion seems of fundamental importance, and we confirmed that deltoid tension that must also be taken into account to improve functional results of reverse shoulder prosthesis on fracture. The ideal humeral elongation seems to be between 10 and 25 mm, in relation to the contralateral side, to obtain better functional results.

Reverse shoulder arthroplasty for proximal humerus fracture: a more complex episode of care than for cuff tear arthropathy

BACKGROUND

The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for reverse total shoulder arthroplasty (RTSA) performed because of proximal humerus fracture (PHFx) vs. cuff tear arthropathy (CTA), and determine whether acute fracture is associated with differences in complications after RTSA.

METHODS

The National Surgical Quality Improvement Program database was queried for RTSA performed for PHFx and CTA. This database contains surgical outcomes within 30 days after the index procedure. Patients underwent a 1:1 propensity matched based on preoperative demographics and comorbidities. Outcomes included operative time, length of stay (LOS), complications, transfusion, readmission, and discharge destination.

RESULTS

A total of 1006 patients (503 per group) were included. With a PHFx, operative time was longer (129.5 ± 54.2 vs. 96.0 ± 40.0 minutes, P < .001), and the patients were more likely to have an adverse event (19.0% vs. 8.2%, P < .001), require transfusion (15.71% vs. 3.98%, P < .001), have longer LOS (3.8 ± 3.6 vs. 2.2 ± 1.7 days, P < .001), and were more likely to be discharged to an extended care facility (27.2% vs. 10.3%, P < .001). PHFx was an independent risk factor for an adverse event after an RTSA.

CONCLUSIONS

RTSA to treat PHFx is associated with longer LOS, increased complications, and discharge to an extended care facility compared with RTSA for CTA. Patients with PHFx require more health care resources than patients with CTA. It is imperative for surgeons, patients, families, governments, hospital systems, and insurance payers to recognize the differences in resource utilization for RTSA in treating PHFx compared with CTA.

Nordic Innovative Trials to Evaluate osteoPorotic Fractures (NITEP) Collaboration: The Nordic DeltaCon Trial protocol-non-operative treatment versus reversed total shoulder arthroplasty in patients 65 years of age and older with a displaced proximal humerus fracture: a prospective, randomised controlled trial

INTRODUCTION

The proximal humerus fracture (PHF) is one of the most common fractures in the elderly. The majority of PHFs are treated non-operatively, while 15%-33% of patients undergo surgical treatment. Recent randomised controlled trial (RCT) and meta-analyses have shown that there is no difference in outcome between non-operative treatment and locking plate or hemi-arthroplasty. During the past decade, reverse total shoulder arthroplasty (RTSA) has gained popularity in the treatment of PHF, although there is a lack of RCTs comparing RTSA to non-operative treatment.

METHODS

This is a prospective, single-blinded, randomised, controlled, multicentre and multinational trial comparing RTSA with non-operative treatment in displaced proximal humeral fractures in patients 65-85 years. The primary outcome in this study is QuickDASH-score measured at 2 years. Secondary outcomes include visual analogue scale for pain, grip strength, Oxford shoulder score, Constant score and the number of reoperations and complications.The hypothesis of the trial is that operative treatment with RTSA produces better outcome after 2 and 5 years measured with QuickDASH.

ETHICS AND DISSEMINATION

In this protocol, we describe the design, method and management of the Nordic DeltaCon trial. The ethical approval for the trial has been given by the Regional Committee for Medical and Health Research Ethics, Norway. There have been several examples in orthopaedics of innovations that result in failure after medium-term follow-ups . In order to prevent such failures and to increase our knowledge of RSTA, we feel a large-scale study of the effects of the surgery on the outcome that focuses on the complications and reoperations is warranted. After the trial 2-year follow-up, the results will be disseminated in a major orthopaedic publication.

TRIAL REGISTRATION NUMBER

NCT03531463; Pre-Results.

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.

Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient

Introduction:

Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly.

Methods:

A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years.

Results:

The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty.

Discussion:

Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis.

Conclusion:

A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.

Grafting and fixation of proximal humeral aseptic non union: a prospective case series

Background

Fractures of the proximal part of the humerus represent almost 4-5% of all fractures. The rate of non union is estimated to be 1.1 to 10%. Non union, displacement, and fixation failure can be hazardous complications for these injuries. The purpose of our study was to evaluate the outcomes of plate and bone strut allograft with bone chips grafting augmentation in the management of proximal humeral aseptic non union.

Methods

We treated 16 aseptic non union proximal humeral fractures by the medial humeral shaft bone strut allograft and lateral plate and screws with bone chips grafting. The patients' ages were between 55 and 70 years. The chosen criteria to evaluate the group during the clinical and radiological follow-up were the quality of life measured by The Short Form (12) Health Survey (SF-12), shoulder function and related quality of life measured by the Constant Shoulder Score (CSS) compared with healthy side, bone healing measured by X-rays, and postoperative complications. The follow-up was perfor med with clinical and radiographic controls at 1, 3, 6 and 12 months. Surgical time and international units of red blood cells transfused were also calculated. The evaluation endpoint was set at 12 months.

Results

The X-rays bone healing occurred in our group on average of 126.4 days after surgery. The surgical time and blood loss were consistent with standard surgical procedures. The quality of life and functional recovery were excellent after plate and bone strut allograft.

Conclusions

Surgical techniques that increase mechanical stability, while incorporating bone biology, are effective aids for treating problematic fractural patterns.

International variation in shoulder arthroplasty

Background and purpose - The number of shoulder registries increases. We assessed international trends in use of shoulder arthroplasty, and described the current state of procedure selection and outcome presentation as documented in national and regional joint registries. Methods - Published reports from 9 population-based shoulder arthroplasty registries (country/region: Norway, Sweden, New Zealand, Denmark, California, Australia, Emilia-Romagna, Germany, and United Kingdom) were analyzed. Data were extracted on age, sex, disease indication, type of surgical procedure, surgical volume, and outcomes. Results - Shoulder arthroplasty incidence rate in 2012 was 20 procedures/10⁵ population with a 6-fold variation between the highest (Germany) and lowest (United Kingdom) country. The annual incidence rate increased 2.8-fold in the past decade. Within the indications osteoarthritis, fracture, and cuff-tear arthropathy variations in procedure choice between registries were large. Outcomes evaluation focused on revision in all registries, but different measures and strata were used. Only Australia provided revision rates for prosthesis brands stratified by both indication and procedure. Finally, in 2 registries with available data surgeons performed on average 10-11 procedures yearly. Interpretation - Annual incidence rates of shoulder arthroplasty have almost tripled over the past decade. There is wide variation in procedure selection for the major indications, a low average surgeon volume, a substantial number of brands with small annual volume, and large variation in outcome presentation. The internationally increasing registry activity is an excellent basis for improving the so far weak evidence in shoulder arthroplasty.

Clinical and radiological outcomes after reverse shoulder arthroplasty with less medialized endoprosthesis after mean follow-up time of 45 months

INTRODUCTION

The purpose of this study was to evaluate outcomes after reverse shoulder arthroplasty for the treatment of complex three- and four-fragment proximal humeral fractures after mean follow-up time of 45 months and to compare our results with the results published by other authors.

MATERIALS AND METHODS

Retrospectively we have analyzed 27 consecutive patients after total arthroplasty with less medialized reverse shoulder prosthesis used for the treatment of complex proximal humeral fracture. The median age and standard deviation was 67.5 ± 7.3 years (range 55-85). The average follow-up time was 45 months. Shoulder function was evaluated using Simple Shoulder Test and Constant scale. Patient satisfaction about the treatment was evaluated using Likert-type questionnaire. All patients were investigated radiologically for possible complications using standard lateral and anterior views.

RESULTS

All patients were satisfied (74%) or highly satisfied (26%). The mean total Constant-Murley score was 57.6 pts. (range 37.4-80.2). Mean total Simple Shoulder Test score was 73.5 pts. (range 49.8-100). There were two cases with heterotopic ossification and one with greater tubercle malposition. We found no signs of scapular notching, implant failure or loosening.

CONCLUSIONS

Results after reverse arthroplasty for complex proximal humeral fractures yield good clinical, functional, and radiological outcomes after mean follow-up time of 45 months. Results are comparable to other studies published in the recent literature.

Glenoid morphology in light of anatomical and reverse total shoulder arthroplasty: a dissection- and 3D-CT-based study in male and female body donors

Background

Placement of the glenoid baseplate is of paramount importance for the outcome of anatomical and reverse total shoulder arthroplasty. However, the database around glenoid size is poor, particularly regarding small scapulae, for example, in women and smaller individuals, and is derived from different methodological approaches. In this multimodality cadaver study, we systematically examined the glenoid using morphological and 3D-CT measurements.

Methods

Measurements of the glenoid and drill hole tunnel length for superior baseplate screw placement were recorded to define size of the glenoid and the distance to the scapular notch on cadaveric specimens. Glenoid angles were determined on both, 3D-CT-scans of the thoraxes using the Friedman method and on subsequently isolated scapulae from 18 male and female donors (average 84 years, range 60–98 years).

Results

Mean glenoid height was 36.6 mm ± 3.6, and width 27.8 mm ± 3.1 with a significant sex dimorphism (p ≤ 0.001): in males, glenoid height 39.5 mm ± 3.5, and width 30.3 mm ± 3.3, and in females, glenoid height 34.8 mm ± 2.2, and width 26.2 mm ± 1.6. The average distance from the superior screw entry to its exit in the scapular notch measured by calliper was 27.2 mm ± 6.0 with a sex difference: in males, 29.4 mm ± 5.7, and in females, 25.8 mm ± 5.9 mm with a minimum recorded distance of 15 mm. Measured by CT, the mean inclination angle for male and female donors combined was 13.0° ± 7.0, and the ante-/retroversion angle −1.0° ± 4.0°.

Conclusion

This study is one of the first to combine dissection, including drill holes, with anatomical measurements and radiological data. In some women and smaller individuals, smaller baseplates should be selected. The published safe zone of 20 mm is generally feasible for superior screw placement, however, in small patients this distance may be substantially shorter than expected and start as of 13 and 15 mm, respectively. No correlation between glenoid height or width with the length of our drilling canal towards the scapular notch was found. Preoperative CT-based treatment planning to determine version and inclination angles is recommended.

Reverse total shoulder arthroplasty: research models

PURPOSE

the past decade has seen a considerable increase in the use of research models to study reverse total shoulder arthroplasty (RTSA). Nevertheless, none of these models has been shown to completely reflect real in vivo conditions.

METHODS

we performed a systematic review of the literature matching the following key words: "reverse total shoulder arthroplasty" or "reverse total shoulder replacement" or "reverse total shoulder prosthesis" and "research models" or "biomechanical models" or "physical simulators" or "virtual simulators". The following databases were screened: Medline, Google Scholar, EMBASE, CINAHIL and Ovid. We identified and included all articles reporting research models of any kind, such as physical or virtual simulators, in which RTSA and the glenohumeral joint were reproduced.

RESULTS

computer models and cadaveric models are the most commonly used, and they were shown to be reliable in simulating in vivo conditions. Bone substitute models have been used in a few studies. Mechanical testing machines provided useful information on stability factors in RTSA.

CONCLUSION

because of the limitations of each individual model, additional research is required to develop a research model of RTSA that may reduce the limitations of those presently available, and increase the reproducibility of this technique in the clinical setting.