Reverse shoulder arthroplasty for proximal humeral fractures: update on indications, technique, and results

Assessment of therapeutic clinical trials for proximal humeral fractures

Proximal humeral fractures (PHFs) are a common injury among the older population. An ideal therapeutic protocol has yet to be developed, and numerous clinical trials are being conducted to find the best therapeutic approach. The purpose of this study is to evaluate the current body of knowledge available via interventional clinical trials. In December 2022, interventional clinical trials relating to PHFs on Clinicaltrials.gov were screened. Trial characteristics included duration, status, intervention, phase, outcomes, location, and study design. Publications associated with each trial were searched on PubMed/Medline using the ClinicalTrials.gov registry number. The final dataset comprised 64 trials. The most common trial status was completed (36%). The majority did not have a Food and Drug Administration-defined phase (67%), was randomized (81%), involved a single facility (72%), used a parallel assignment intervention model (80%), and used an open-label approach (45%). Eleven trials were associated with a publication, and the publication rate was 17%. Average enrollment was 86 participants, and mean trial duration was 51.4 months. Europe/UK/Russia/Turkey participated in the most trials (70%). Most of the trials were initiated after 2010 (87.5%). Procedure-related interventions (55%) were most common. Disability/function was the most common primary outcome assessed (61%). The low publication rate and the multitude of trials conducted after 2010 highlight the urgency and need for trial results to be published to establish an ideal therapeutic protocol. Since the majority of the trials involved a single institution and an open-label approach, reinforcing blinding and establishing multi-centered trials can improve the validity of the clinical trial results.

Electromyographic analysis of selected shoulder muscles during shoulder rehabilitation exercises in patients after reverse total shoulder arthroplasty

BACKGROUND

Reverse shoulder arthroplasty (RSA) aims to restore function in patients with rotator cuff failure and joint arthropathy. After surgery, patients are routinely referred to a rehabilitation specialist to regain range of motion, strength, and function. A key element in these programs is active exercises. The exercises are often selected based on assumed muscle activity, investigated by electromyography (EMG). In particular, in this patient population, activation of the deltoid and the scapular muscles is the focus of exercise therapy. Currently, most studies investigating muscle activity levels during exercises are performed on healthy individuals. To our knowledge, no study exists analyzing EMG activity during exercises in a population of shoulder arthroplasty patients. Therefore, the study aimed to analyze activity in the shoulder girdle muscles during 6 commonly used rehabilitation exercises 12 weeks after reverse shoulder arthroplasty surgery.

METHODS

Forty-four patients (50 shoulders) participated in this cross-sectional study, 12 weeks postoperatively (mean 99.18 ± 12.8 days), aged 68.9 ± 7.75 years. Surface EMG activity was measured in 10 shoulder girdle muscles: the 3 trapezius parts, serratus anterior, the 3 deltoid parts, latissimus dorsi, and 2 pectoralis major parts during 6 exercises, 3 in a closed chain, and 3 open chain elevation exercises.

RESULTS

Gravity-minimized exercises (horizontal plane) show low activity for almost all muscles. Vertical closed kinetic chain exercises show an increased activity compared to horizontal plane exercises. Open kinetic chain exercises against gravity showed the greatest activity in deltoid and upper trapezius. For the other muscles, no consistency in progression was found.

CONCLUSION

This study offers a progression of exercises for patients after reverse shoulder arthroplasty based on increased muscle activity.

Reverse total shoulder arthroplasty within 6 weeks of proximal humerus fracture is associated with the lowest risk of revision

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHFs). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals.

METHODS

A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2 years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF).

RESULTS

In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified 2 timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6-week cohort, the 7-52-week cohort was more likely to undergo revision surgery within 2 years (OR 1.93, P < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001).

CONCLUSIONS

Using SSLR, we were successful in identifying 2 data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

Mid-term outcomes following reverse total shoulder arthroplasty

PURPOSE

The utilization of reverse total shoulder arthroplasty now exceeds the incidence of anatomic shoulder arthroplasty. Previous mid-to-long-term studies on rTSA have reported a decrease in shoulder function as follow-up increased. The purpose of this study was to provide data on mid-term outcomes and implant survival in a series focusing on reverse total shoulder arthroplasty.

MATERIALS AND METHODS

Demographic information such as age at surgery, revision surgery status, BMI, and smoking status were recorded. The clinical endpoints measured in this study were range of motion scores (forward elevation, external rotation, internal rotation) and patient reported outcomes (VAS, ASES, SST). Radiographic variables captured included preoperative glenoid morphology, humeral lucency, and glenoid loosening.

RESULTS

Fifty-six shoulders were included in this study. The overall mean age at surgery was 72.5 ± 7.2 years with an average follow-up time of 6.8 ± 3.5 years. The mean BMI was 28.1 ± 5.5. All measurements of range of motion saw significant and sustained improvements. Overall, forward elevation improved from 82° preoperatively to 133° postoperatively (p < 0.01). External rotation improved from 23° preoperatively to 36° (p < 0.01), while internal rotation improved from L3 to L1 (p = 0.05). ASES scores improved from 31 preoperatively to 70 postoperatively (p < 0.01). SST scores improved from 2 preoperatively to 7 (p < 0.01). VAS pain index scores improved from 6 to 2 following surgery (p < 0.01). Postoperative scapular notching was seen in 18 patients at final follow-up. Glenoid loosening was seen in 3 shoulders. Humeral loosening was seen in 18 shoulders. Tuberosity resorption was seen in 8 shoulders. The 5 year survival estimate was 98%, and the 10 year survival estimate was 83%.

CONCLUSION

In this series, we found that rTSA provides mid-term improvements in range of motion in patients while reducing pain levels. When considered together, this demonstrates that most patients undergoing rTSA can have excellent use of their shoulder from age at surgery to end-of-life.

Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study

Background

About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes.

Methods

In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared.

Results

Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7).

Conclusion

Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.

Design of a reverse shoulder implant to measure shoulder stiffness during implant component positioning

To avoid dislocation of the shoulder joint after reverse total shoulder arthroplasty, it is important to achieve sufficient shoulder stability when placing the implant components during surgery. One parameter for assessing shoulder stability can be shoulder stiffness. The aim of this research was to develop a temporary reverse shoulder implant prototype that would allow intraoperative measurement of shoulder stiffness while varying the position of the implant components. Joint angle and torque measurement techniques were developed to determine shoulder stiffness. Hall sensors were used to measure the joint angles by converting the magnetic flux densities into angles. The accuracy of the joint angle measurements was tested using a test bench. Torques were determined by using thin-film pressure sensors. Various mechanical mechanisms for variable positioning of the implant components were integrated into the prototype. The results of the joint angle measurements showed measurement errors of less than 5° in a deflection range of ±15° adduction/abduction combined with ±45° flexion/extension. The proposed design provides a first approach for intra-operative assessment of shoulder stiffness. The findings can be used as a technological basis for further developments.

Anatomic greater tuberosity healing does not influence the functional outcomes of reverse shoulder arthroplasty for acute proximal humerus fractures

Background

To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity.

Method

It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores.

Results

The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores.

Conclusion

After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.

[Translated article] Influence of lateralized reverse shoulder prosthesis design on tuberosity union in proximal humerus fractures

INTRODUCTION

Proximal humerus fractures are the third most frequent type of fracture in elderly patients. Nowadays, surgical treatment is indicated one third of the time, being the reverse shoulder prosthesis an option especially in complex comminuted patterns. In this study we analyzed the effects of a lateralized reverse prosthesis in tuberosity union and its relationship with the functional results.

MATERIAL AND METHODS

Retrospective case study of patients with proximal humerus fractures treated with a lateralized design reverse shoulder prosthesis with one-year minimum follow-up. Tuberosity nonunion was defined as a radiological concept: absence of tuberosity, distance >1cm from the tuberosity fragment to the humeral shaft or tuberosity above the humeral tray. Subgroup analysis was performed, group 1 (n=16) tuberosity union vs. group 2 (n=19) tuberosity nonunion. Groups were compared with the following functional scores: Constant, American Shoulder and Elbow Surgeons and Subjective Shoulder Value.

RESULTS

A total of 35 patients were included in this study with a median age of 72.65 years. Postoperative radiographic analysis at one year after surgery revealed a tuberosity nonunion rate of 54%. Subgroup analysis revealed no statistically significant differences in terms of range of motion or functional scores. However, there were differences regarding the Patte sign (p=0.03) which was positive in a larger proportion of patients in the group with tuberosity nonunion.

CONCLUSION

Even though there was a large percentage of tuberosity nonunion with the use of a lateralized prosthesis design, patients obtained good results in a similar manner to those found in the union group in terms of range of motion, scores, and patient satisfaction.

Reverse total shoulder arthroplasty for complex proximal humerus fracture in the elderly: clinical and radiological results

Background

The use of reverse total shoulder arthroplasty (RSA) for the treatment of proximal humeral fractures (PHFs) is steadily increasing. Better clinical outcomes of RSA have been correlated with tuberosity reattachment and healing. The purpose of this study was to evaluate both the clinical and radiological results of reverse shoulder arthroplasty in the management of a proximal humerus fracture in the elderly.

Methods

Retrospective study including 400 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 12-month follow-up. In all the cases, the greater tuberosity was reattached with a standardized suture technique and a local bone graft. All the patients were assessed at the 12-month follow-up with Constant-Murley Score (CMS). Radiographic healing of the greater tuberosity was noted. Complications and revision rates were reported.

Results

Mean final CMS for this cohort was 82 points. The greater tuberosity healed in anatomic position in 85% of the cases (N = 340), obtaining an average CMS of 85 in these patients. Healing of the greater tuberosity did not occur in 13% of the cases (N = 52) and displacement more than 5 mm occurred in 2% (N = 8) of the patients for an average CMS of 60. All patients scored above 120° in forward elevation with a mean of 150°. Mean active external rotation was 35°. The lateralization shoulder angle had a mean of 91° and the distalization shoulder angle had a mean of 54°. Low-grade scapular notching was reported in <1% of the cases. A total of 60 patients presented failure of healing or displacement of the greater tuberosity. Major complications were reported in nine patients. Of these nine patients, two acquired superficial wound infections, while two had deep shoulder prosthetic infection. Two other patients developed hematomas, one sustained an acromial stress fracture, and two had a stem loosening. There were 4 reoperations.

Conclusion

Reverse shoulder arthroplasty, with the use of a fracture-specific stem, allows an improved rate of greater tuberosity healing and short-term clinical outcomes in the elderly population.

Reverse shoulder arthroplasty versus hemiarthroplasty versus non-surgical treatment for older adults with acute 3- or 4-part fractures of the proximal humerus: study protocol for a randomised controlled trial (PROFHER-2: PROximal Fracture of Humerus Evaluation by Randomisation - Trial Number 2)

BACKGROUND

Proximal humerus fractures (PHF) are common and painful injuries, with the majority resulting from falls from a standing height. As with other fragility fractures, its age-specific incidence is increasing. Surgical treatment with hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA) have been increasingly used for displaced 3- and 4-part fractures despite a lack of good quality evidence as to whether one type of arthroplasty is superior to the other, and whether surgery is better than non-surgical management. The PROFHER-2 trial has been designed as a pragmatic, multicentre randomised trial to compare the clinical and cost-effectiveness of RSA vs HA vs Non-Surgical (NS) treatment in patients with 3- and 4-part PHF.

METHODS

Adults over 65 years of age presenting with acute radiographically confirmed 3- or 4-part fractures, with or without associated glenohumeral joint dislocation, who consent for trial participation will be recruited from around 40 National Health Service (NHS) Hospitals in the UK. Patients with polytrauma, open fractures, presence of axillary nerve palsy, pathological (other than osteoporotic) fractures, and those who are unable to adhere to trial procedures will be excluded. We will aim to recruit 380 participants (152 RSA, 152 HA, 76 NS) using 2:2:1 (HA:RSA:NS) randomisation for 3- or 4-part fractures without joint dislocation, and 1:1 (HA:RSA) randomisation for 3- or 4-part fracture dislocations. The primary outcome is the Oxford Shoulder Score at 24 months. Secondary outcomes include quality of life (EQ-5D-5L), pain, range of shoulder motion, fracture healing and implant position on X-rays, further procedures, and complications. Independent Trial Steering Committee and Data Monitoring Committee will oversee the trial conduct, including the reporting of adverse events and harms.

DISCUSSION

The PROFHER-2 trial is designed to provide a robust answer to guide the treatment of patients aged 65 years or over who sustain 3- and 4-part proximal humeral fractures. The pragmatic design and recruitment from around 40 UK NHS hospitals will ensure immediate applicability and generalisability of the trial findings. The full trial results will be made available in a relevant open-access peer-reviewed journal.

TRIAL REGISTRATION

ISRCTN76296703. Prospectively registered on 5th April 2018.

Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes

Background

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae.

Methods

Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk.

Results

The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P = .102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P = .004), lower rate of previous procedure (4.3% vs. 51.9%; P < .001), lower bone graft use (28.6% vs. 59.6%; P < .001), and a longer length of stay (5.9 vs. 3.0 days; P < .001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P = .523), forward elevation (98° vs. 93°; P = .627), external rotation (30° vs. 23°; P = .215), internal rotation score (4.0 vs. 4.5; P = .589), satisfaction (P = .592), ASES scores (64.4 vs. 57.1; P = .168), complications (27.1% vs. 28.8%; P = .836), or reoperations (11.4% vs. 19.2%; P = .229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P = .172), with 15-year reoperation rates of 13.7% and 24%, respectively (P = .098).

Conclusions

HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty

INTRODUCTION

The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA) and hemiarthroplasty for the treatment of proximal humerus fractures.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018.

RESULTS

One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications.

DISCUSSION

There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants.

Shoulder Proprioception Following Reverse Total Shoulder Arthroplasty for Unreconstructable Upper Third Fractures of the Humerus: 2-Year Outcomes

Background

Proximal humerus fractures may be comminuted in the elderly or after injury with high-energy mechanisms. Reverse total shoulder arthroplasty that may affect shoulder proprioception (rTSA) has also begun to play a part in treating acute proximal humeral fractures. In this study, the authors aimed to evaluate joint position sense (JPS) after rTSA.

Methods

Humac Norm II isokinetic device was used to evaluate the joint position sense. A joint angle was determined and the ability of the patient to create the same value of the angle by the active movement was evaluated. The difference between the pre-determined angle and the patient's measured angle was recorded. For proprioceptive sense, the initial position was 0° and the determination position was 30°, 60°, and 90° for flexion and abduction, and 15° and 30° for internal rotation and external rotation.

Results

While both the mean Constant and ADLEIR scores did not differ between non-operated and operated sides, the mean proprioception differences in all flexion (30°, 60°, and 90°), abduction (30°, 60°, and 90°), internal rotation (15° and 30°), and external rotation (15° and 30°) were significantly higher in the operated side than that in non-operated side (p < 0.01 for each pairwise comparison).

Conclusion

Reverse total shoulder arthroplasty (rTSA) treatment, which has increasingly become a surgical option in un-reconstructable proximal humeral fractures has significant adverse effects on proprioception on the operated side and may pose a risk for long-term instability, premature loosening, and prosthesis mechanical complications, in this context, well-designed prospective controlled studies are required.

Influence of lateralized reverse shoulder prosthesis design on tuberosity union in proximal humerus fractures

INTRODUCTION

Proximal humerus fractures are the third most frequent type of fracture in elderly patients. Nowadays, surgical treatment is indicated one third of the time, being the reverse shoulder prosthesis an option especially in complex comminuted patterns. In this study we analyzed the effects of a lateralized reverse prosthesis in tuberosity union and its relationship with the functional results.

MATERIAL AND METHODS

Retrospective case study of patients with proximal humerus fractures treated with a lateralized design reverse shoulder prosthesis with one-year minimum follow-up. Tuberosity nonunion was defined as a radiological concept: absence of tuberosity, distance>1cm from the tuberosity fragment to the humeral shaft or tuberosity above the humeral tray. Subgroup analysis was performed, group 1 (n=16) tuberosity union vs. group 2 (n=19) tuberosity nonunion. Groups were compared with the following functional scores: Constant, American Shoulder and Elbow Surgeons and Subjective Shoulder Value.

RESULTS

A total of 35 patients were included in this study with a median age of 72.65 years. Postoperative radiographic analysis at one year after surgery revealed a tuberosity nonunion rate of 54%. Subgroup analysis revealed no statistically significant differences in terms of range of motion or functional scores. However, there were differences regarding the Patte sign (p=0.03) which was positive in a larger proportion of patients in the group with tuberosity nonunion.

CONCLUSION

Even though there was a large percentage of tuberosity nonunion with the use of a lateralized prosthesis design, patients obtained good results in a similar manner to those found in the union group in terms of range of motion, scores, and patient satisfaction.

Biomechanical analysis of the interval slide procedure: a fresh porcine cadaver study

INTRODUCTION

The interval slide procedure (IS) has been introduced to improve mobility in massive, retracted rotator cuff tears. As clinical studies showed controversial results, the benefit of the IS is still widely discussed.

AIM

Aim of this study was to analyze the effect of IS procedure on tendon mobility in a fresh porcine cadaver model.

MATERIALS AND METHODS

In 30 fresh porcine cadaver shoulders with artificial supraspinatus defect tendon mobility was tested by measuring the load (in N) during tendon reduction to the footprint at the greater tubercle using a sensor enhanced arthroscopic grasper (t1). In intervention group (N = 15) anterior IS (t2), posterior IS (t3) and intraarticular capsule release (t4) were successively performed, each followed by tendon mobility assessment. Tendon mobility of the control group (N = 15) was measured in same time schedule without intervention.

RESULTS

Mobility did not differ between groups for native tendons (CG 28.0 ± 11.2 N vs. IG 26.6 ± 11.6 N; P = 0.75). IS procedure significantly improves mobility at about 25.2% (t1 26.6 ± 11.6 N vs. t4 19.9 ± 12.3 N; P < 0.001) compared to the native tendon and 34.1% compared to CG (CG 30.2 ± 13.7 N vs. 19.9 ± 12.3 N; P = 0.026). In posthoc analyzes, anterior IS (P < 0.001) and capsule release (P = 0.005) significantly increased mobility, whereas the posterior IS did not (P = 0.778).

CONCLUSION

The IS procedure results in increased supraspinatus tendon mobility in fresh porcine cadaver shoulders. However, performing the posterior IS subsequent to the anterior IS no significant improvement of mobility has been observed.

Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty

Background

This study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA).

Methods

This is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables.

Results

A total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05).

Conclusion

The management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group.

Prospective multicentre mid-term clinical and radiological outcomes of 159 reverse total shoulder replacements and assessment of the influence of post-operative complications

BACKGROUND

The aim of our prospective multicentre study is to evaluate the five-year follow-up outcomes of primary reverse shoulder replacement utilizing two different designs of glenoid baseplates.

METHODS

There were 159 reverse shoulder replacements (91 cemented and 68 uncemented stems, 67 Trabecular Metal baseplates and 92 Anatomical Shoulder baseplates in 152 patients (99 women) with a mean age of 74.5 (58-90) years. The principal diagnosis was rotator cuff arthropathy in 108 shoulders.

RESULTS

Clinical and functional results improved significantly overall; the adjusted Constant Murley score improved from 28.2 ± 13.3 pre-operatively to 75.5 ± 22.8 (p < 0.0001) and the mean Subjective Shoulder Value improved from 27.5 ± 20 to 73.8 ± 21.3 points (p < 0.0001). Radiologically, there was good bony stability in 88% and 86% of cemented and uncemented stems without significant impact on the Constant Murley score and Subjective Shoulder Value at one, two and five years post-surgery. There were no significant clinical differences between Trabecular Metal and Anatomical Shoulder baseplates at five years. There were four cases of intraoperative shaft fractures that were managed with cables. Although the Trabecular Metal baseplates showed better integration radiologically, there was no significant difference in the mean of Constant Murley, Subjective Shoulder Value and the range of motion depending on the grade of inferior scapular notching at one-, two- and five-year intervals.

CONCLUSIONS

Reverse total shoulder arthroplasty restores the function in shoulder with significant improvements in function and moderate complications with minor differences between both designs of baseplates that were not reflected clinically.

Reverse Shoulder Arthroplasty for Failed Operative Treatment of Proximal Humeral Fractures

Introduction

Failure after operative treatment of complex proximal humeral fractures (PHF) can prove challenging even for experienced surgeons. Reverse shoulder arthroplasty (RSA) seems to offer a satisfactory revision procedure with good clinical outcomes.

Materials and Methods

We present a case series of 14 patients, who were treated during a 3.5 years period (from 01/2016 until 06/2019). They all underwent revision surgery with RSA for failed operative treatment of PHF. Their mean age was 68 years (range, 51-84 years). 2 patients (14.3%) had been primarily treated with open reduction and internal fixation (ORIF), 5 patients (35.7%) with hemiarthroplasty, 3 patients (21.4%) with closed reduction and percutaneous fixation and 4 patients (28.6%) with transosseous suture fixation (TSF). We evaluated their absolute Constant score (CS), Visual Analogue Scale (VAS) score, and Range of Motion at their final follow-up, and we made a full clinical and radiological assessment to detect any postoperative complications.

Results

The mean absolute CS, VAS score, active anterior elevation, active abduction significantly improved compared with the preoperative status. Less significant difference was found in external rotation when comparing with the preoperative status (P = .0304). No significant differences were found when comparing RSA for different failed primary techniques (P > .05). No complications were detected following the revision surgeries of all patients.

Conclusion

RSA is an appropriate treatment as a revision technique for failed primary surgical treatment of PHFs. Though challenging it can offer good clinical results and pain relief.

Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient

BACKGROUND

Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly.

METHODS

We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up.

RESULTS

Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%.

CONCLUSION

In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.

Current Role of Reverse Total Shoulder Arthroplasty for Fractures of the Proximal Humerus

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

Surgical learning curve in reverse shoulder arthroplasty for proximal humerus fractures

Background

Fracture reverse shoulder arthroplasty (fRSA) in geriatric, complex dislocated proximal humerus fractures is becoming the standard treatment next to conservative treatment. fRSA is a multifaceted, reasonably challenging procedure of which functional outcomes and complication rates are likely to depend on the experience of the surgeon. The goal of this study was to determine whether there is a learning curve for fRSA.

Methods

All patients with a dislocated multipart proximal humerus fracture that were treated with an fRSA between 2013 and 2019 in a specialized institution were included. The functional outcomes (Constant Shoulder Score, Oxford Shoulder Score, and range of motion), complications, and operation time of fRSA were assessed with linear regression plots and cumulative summation analysis to establish whether a learning curve was present.

Results

In this cohort study, 50 patients were included. They had a mean age of 77.1 years and were treated with an fRSA by one trauma surgeon. Learning curves were distinguished for functional outcomes, complications, and operation time based on learning targets for daily activity and the mean complications and operation time. Results indicated that an optimal treatment is achieved after performing 20 fRSAs.

Conclusion

The results show that functional outcomes of PHFs treated with an fRSA improve with surgical experience. Also, outcomes are getting less variable after about 20 procedures. Surgeons starting this procedure should be aware of the learning curve and, therefore, should consider guidance from an experienced surgeon to swiftly optimize functional outcomes and prevent unnecessary complications.

Reverse shoulder arthroplasty in complex fractures of the proximal humerus: results after 7 years of follow-up

BACKGROUND

There is still little information about the long-term results of clinical and radiological evolution in patients older than 65 years with complex proximal humerus fractures (CPHF) treated acutely with reverse shoulder arthroplasty (RSA). The aim of this paper was to evaluate function and results 7 years after surgery.

MATERIAL AND METHODS

A prospective cross-sectional cohort study was designed for this purpose. Patients who underwent RSA surgery during 2012 because of a CPHF were included. The surgical approach was randomized (deltopectoral vs anterosuperior). Functional activity, evolution of tuberosities and evidence of scapular notching 7 years after surgery were analyzed.

RESULTS

After evaluating 32 patients, the Constant score improved from 64.83 in the first year to 69.54 at 7 years postoperative. Results were independent of the approach used. Functional outcomes were poorer in patients with scapular notching and when tuberosities were resorbed or displaced.

CONCLUSIONS

At 7 years, function in patients undergoing RSA after CPHF demonstrated improvement in all patients except those who developed scapular notching or when tuberosities did not consolidate in an anatomical position. These results are completely independent of the approach used.

LEVEL OF EVIDENCE

III Controlled cohort study.

Acute versus delayed reverse total shoulder Arthroplasty for the management of Proximal Humerus Fractures

OBJECTIVES

Proximal humerus fractures (PHF) are common, yet their optimal management remains debated. Reverse total shoulder arthroplasty (rTSA) is an increasingly popular option, particularly for non-reconstructible or osteoporotic fractures. Despite this trend, current literature provides limited guidance with regards to surgical timing and patient selection for rTSA. A trial of non-operative management might be beneficial for many patients who are not clearly indicated for surgery, provided this does not have a major negative impact on results for those who ultimately require rTSA. The purpose of this study was to investigate whether delayed reverse shoulder arthroplasty for fracture (>28 days from injury) is associated with any difference in complication rates or functional outcomes relative to acute surgery.

DESIGN

Retrospective cohort study PATIENTS/PARTICIPANTS: 114 consecutive patients who underwent rTSA as the primary management of a PHF at two Level 1 trauma centers and one academic community hospital between 2004 and 2016.

INTERVENTION

rTSA as primary management of proximal humerus fracture MAIN OUTCOME MEASUREMENTS: Complications, range of motion, and patient-reported functional outcomes scores (DASH, PROMIS physical function, and EQ-5D) RESULTS: Eighty-two of 114 patients (72%) underwent early surgery. Complex (4-part, head-split, dislocated) fractures were significantly more common in the acutely treated group. There was no significant difference in complications. Overall complication rate was 11.4%. There was a significant difference in DASH score favoring early surgery, with an average score of 22.4 in acutely treated patients versus 35.1 in delayed patients (p = 0.034). There was a non-statistically significant trend towards better PROMIS physical function scores and ROM in the acutely treated group.

CONCLUSION

Delay in performing primary rTSA for management of PHF does not lead to an increase in complication rates but it may come at the cost of worse functional outcomes in patients who ultimately require rTSA.

Patient risk factors for acromial stress fractures after reverse shoulder arthroplasty: a multicenter study

BACKGROUND

Despite the growing recognition of acromial stress fractures (ASFs) after reverse total shoulder arthroplasty (RTSA), most of the current data are derived from single-center studies with limited generalizability. This multicenter study investigated the incidence of ASFs after RTSA and identified preoperative patient characteristics associated with their occurrence.

METHODS

Using 2 institutional registries from different regions of the United States, we identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). Multivariable logistic regression was performed to identify preoperative patient factors associated with the development of ASFs.

RESULTS

Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex (odds ratio [OR], 2.21 reference: male; 95% confidence interval [CI], 1.03-4.74; P < .05), rheumatoid arthritis (OR, 2.30; 95% CI, 1.02-5.16; P < .05), osteoporosis (OR, 2.55; 95% CI, 1.24-5.21; P < .05), a diagnosis of degenerative joint disease with rotator cuff tear (OR, 4.74 reference: degenerative joint disease without rotator cuff tear; 95% CI, 1.84-12.23; P < .05), and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P < .05).

CONCLUSIONS

The non-negligible percentage of ASFs that occur after RTSA is associated with the diagnoses of rotator cuff dysfunction and chronic fracture sequelae in female patients with suboptimal bone health. This information can be used to counsel patients and set expectations about potential setbacks in recovery.

Correlation and responsiveness of global health, upper extremity-specific, and shoulder-specific functional outcome measures following reverse total shoulder arthroplasty for proximal humerus fracture

PURPOSE

Reverse total shoulder arthroplasty (rTSA) is effective and increasingly utilized for the management of proximal humerus fracture (PHF). However, the optimal patient-reported outcome metrics (PROMs) for the evaluation of patient outcomes after this surgery are unclear. We investigated the correlation among global, upper extremity-specific, and shoulder-specific PROMs in patients undergoing rTSA for PHF as well as the responsiveness of these PROMs as assessed by floor and ceiling effects. We hypothesized that patients' post-operative outcome would be best reflected by a combination of these metrics.

METHODS

Thirty patients with a history of rTSA for ipsilateral PHF filled out the following outcomes questionnaires at a minimum of 3 years post-op: EQ-5D, EQ-5D VAS, PROMIS physical function, DASH, SSV, SPADI, and ASES. Correlation between metrics was assessed using the Spearman correlation coefficient. Responsiveness was assessed by comparing the proportion of patients reaching floor or ceiling values using McNemar's test.

RESULTS

Global health metrics (EQ-5D and PROMIS physical function) were strongly correlated with the upper extremity-specific metric (DASH). Shoulder-specific outcomes (SPADI, ASES, and ASES) were moderately correlated with both the global metrics and DASH. There was no significant difference between PROMs with regards to floor and ceiling effects.

CONCLUSIONS

The DASH score has been shown to be valid and responsive for shoulder interventions, and our data demonstrate that it correlates strongly with overall quality of life. Shoulder-specific metrics are valid and responsive for shoulder interventions but correlate less with global quality of life. An optimal PROM strategy in rTSA for PHF might involve both DASH and a shoulder-specific score. Based on our assessment of floor and ceiling effects, none of these metrics should be excluded for poor responsiveness.

More Adverse Events after Osteosyntheses Compared to Arthroplasty in Geriatric Proximal Humeral Fractures Involving Anatomical Neck

The purpose of this study was to compare adverse events and clinical outcomes of geriatric proximal humerus fractures (PHF) involving the anatomical neck (type C according to AO classification) treated with open reduction and internal fixation (ORIF) using locking plate vs. arthroplasty. In this retrospective cohort study, geriatric patients (>64 years) who underwent operative treatment using ORIF or arthroplasty for type C PHFs were included. Complications, revisions and clinical outcomes using Constant Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) Score were assessed and compared between groups. At a mean follow up of 2.7 ± 1.7 years, 59 patients (mean age 75.3 ± 5.5 years) were included. In 31 patients ORIF was performed and 29 patients underwent arthroplasty. Complications and revision surgeries were significantly more frequent after ORIF (32.6% vs. 7.1%, p = 0.023 and 29.0% vs. 7.1%, p = 0.045). In contrast, clinical outcomes showed no significant differences (DASH 39.9 ± 25.7 vs. 39.25 ± 24.5, p = 0.922; CMS 49.7 ± 29.2 vs. 49.4 ± 25.2, p = 0.731). ORIF of type C PHFs in geriatric patients results in significantly more complications and revision surgery when compared to arthroplasty. Therefore, osteosynthesis of geriatric intraarticular fractures of the proximal humerus must be critically evaluated.

Histological characteristics of bone in-growth of proximal humeral implants with different spatial structures

This study compares the longitudinal histological characteristics of proximal humeral implants with different spatial structures in rabbits. Thirty skeletally-mature male rabbits were divided into a trabecular structure group and regular hexahedron structure group according to the different spatial structures of a biological titanium alloy screw inserted into the greater tuberosity of the proximal humerus. Samples were collected 3, 6, and 12 weeks after the implantation surgery. Histological results showed that the amount of bone in-growth in the porous cavity of the screw implant increased over time. Quantitative analysis showed there was significantly more bone in-growth in the trabecular structure group than the classic structure group 3 weeks (25.4% ± 6.9% vs 19.6% ± 3.7%, P < 0.05) and 6 weeks (31.2% ± 1.7% vs 26.9% ± 5.3, P < 0.05) after the implantation surgery. No significant difference was detected between the two groups 12 weeks after the surgery (41.7% ± 2.5% vs 39% ± 4.1%, P > 0.05). Our data found that bone in-growth significantly differed among the three time points (P < 0.05) in both groups, but not between the implants with different spatial structures 12 weeks after the surgery.

Return to sport following reverse shoulder arthroplasty: a systematic review

BACKGROUND

The purpose of this study is to systematically review the evidence in the literature to ascertain the rate and timing of return to sport following reverse shoulder arthroplasty (RSA).

METHODS

A systematic literature search based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to sport following RSA. Statistical analysis was performed using SPSS.

RESULTS

Overall, 8 studies including 455 patients (464 shoulders) met our inclusion criteria. The majority of patients were female (77.7%), with an average age of 74.2 years. The overall rate of return to sport was 79.1%; with 66.7% of golfers, 74.3% of swimmers, 50.0%, of tennis players, 94.4% of joggers, and 69.7% of cyclists returning. In addition, 71.4% of patients returned to the same level of sporting activity. The average time to return to sport was 3.4 months with a mean follow-up of 34.0 months.

DISCUSSION AND CONCLUSION

The results from our systematic review show that the majority of patients are able to return to sport following RSA, with a large number returning to the same level of sport. However, results were modest in overhead athletes, with a concerning number unable to return to tennis post-RSA.

Do patient outcomes and follow-up completion rates after shoulder arthroplasty differ based on insurance payor?

BACKGROUND

Disparities associated with socioeconomic status (SES) and insurance coverage have been shown to affect outcomes in different medical conditions and surgical procedures. We hypothesized that patients insured by Medicaid will be associated with lower follow-up rates and inferior outcomes relative to those with Medicare or private insurance.

METHODS

Patients undergoing shoulder arthroplasty, including anatomic total shoulder arthroplasty, reverse arthroplasty, and hemiarthroplasty, were enrolled preoperatively in an institutional database. Preoperative demographics, payor (Medicaid, Medicare, or private insurance), and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores were recorded. Postoperatively, patients completed ASES scores at multiple time points. Follow-up completion rate was calculated as the number of follow-up visits completed relative to possible visits. Continuous variables were compared between groups with 1-way analyses of variance, and chi-squared tests were used for categorical variables. Significance was defined as P < .05.

RESULTS

There were 491 shoulder replacements performed for 438 patients from 2012-2017. The mean follow-up completed percentage was significantly lower (P < .001) for Medicaid patients (62.6% ± 33.7%) relative to Medicare patients (80.2% ± 26.7%; P < .001) and private insurance patients (77.8% ± 22.1%; P = .001). The ASES Composite score increased significantly for all patients from baseline to final follow-up. At each time point, including before surgery and each postoperative time point, patients with Medicaid insurance had significantly lower ASES Composite scores. The final ASES Composite score was significantly lower in the Medicaid patients (66.1 ± 28.7) relative to private insurance patients (78.3 ± 20.8; P = .023). Medicaid patients had significantly lower preoperative (P < .001) and postoperative (P = .018) ASES Pain subscores. In multivariate regression analysis, Medicaid insurance was associated with both inferior preoperative and postoperative ASES scores relative to patients with Medicare or private insurance.

CONCLUSIONS

We observed that all patients, regardless of insurance payor, improved by similar magnitudes after shoulder arthroplasty, though patients with Medicaid insurance had significantly lower preoperative and postoperative ASES scores, primarily because of the ASES Pain subscore. Patients with Medicaid insurance also have lower follow-up rates than other payors.

Surgical treatment of complex proximal humeral fractures in elderly patients: a matched-pair analysis of angular-stable plating vs. reverse shoulder arthroplasty

BACKGROUND

To date, there is a lack of consensus regarding the type of surgical treatment for complex proximal humeral fractures (PHFs) in elderly patients, especially between joint preservation and joint replacement techniques.

MATERIALS AND METHODS

We matched 60 patients (aged 73.2 ± 6.4 years) with complex PHFs in terms of sex, age, and Charlson Comorbidity Index, who underwent locking-plate open reduction-internal fixation (ORIF) or reverse shoulder arthroplasty (RSA) (2011-2017). Postoperative range of motion and functional outcome were assessed using the American Shoulder and Elbow Surgeons shoulder score, Oxford Shoulder Score, Constant-Murley score, and Disabilities of the Arm, Shoulder and Hand score at a mean follow-up of 49 months (ORIF group) and 38 months (RSA group). Complications and unplanned revision surgery were recorded, and all radiographs were analyzed.

RESULTS

ORIF resulted in numerically, although not statistically significantly, greater mean shoulder motion vs. RSA. Significantly better outcome was reported for the Oxford Shoulder Score (P = .034) and Disabilities of the Arm, Shoulder and Hand score (P = .026) in the ORIF group, although no significant differences were observed in the American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score. The complication rate (30% vs. 10%) and revision rate (20% vs. 3%) were significantly higher in the ORIF group (P = .028), with patients who had complications or required revision having worse functional results.

CONCLUSION

Favorable results are achievable through both angular-stable plating and RSA. Although ORIF may be associated with a superior functional outcome, exceeding the minimal clinically important difference, RSA was linked to significantly fewer complications and revisions.

Acute surgical management of proximal humerus fractures: ORIF vs. hemiarthroplasty vs. reverse shoulder arthroplasty

BACKGROUND

Proximal humerus fracture treatment varies by surgeon preference and patient factors. This study compares patient and fracture characteristics, with outcomes between current surgical treatment options.

METHODS

Between 1999 and 2018, 425 proximal humerus fractures underwent acute surgical management: open reduction internal fixation (ORIF, n = 211), hemiarthroplasty (HA, n = 108), or reverse shoulder arthroplasty (RSA, n = 106). Patient and fracture characteristics included age, American Society of Anesthesiologists physical status classification (ASA), and fracture classification. Postoperative motion at 3, 6, and minimum 12 months (avg 20 ± 21 months), radiographic outcomes, and postoperative falls were analyzed.

RESULTS

Average age for treatment groups was 65 ± 13 years (range: 18-93 years). Fractures were classified as 2- (11%), 3- (41%), or 4-part (48%). Age, ASA, and fracture classification were associated with selected surgical management (P < .0001, =.001, <.0001, respectively). Outcomes showed a significant improvement in forward flexion from 3 months to 6 months in all groups (P < .0001). No difference in final motion was seen between groups. Radiographic union was higher in ORIF (89%), and similar between HA (79%) and RSA (77%, P = .005). Rate of reoperation was RSA 6.6%, ORIF 17.5%, and hemiarthroplasty 15.7% (P = .029). Postoperatively, 23% patients had at least 1 fall, of which 73% resulted in fractures.

CONCLUSION

Older patients with high ASA were treated with arthroplasty, and younger patients with lower ASA were treated with ORIF. All groups showed improvements in motion. At minimum 1 year of follow-up, there was no difference in motion between groups. ORIF and HA showed significantly more reoperations compared with RSA. Patients should be counseled about reoperation, fall risk, and prevention.

Changing trends in the management of proximal humerus fractures in New York State

Purpose

Reverse shoulder arthroplasty (RSA) as an alternative to hemiarthroplasty (HA) as treatment for proximal humerus fractures has prompted a re-evaluation of utilization trends.

Methods

Operative treatment for proximal humeral fractures were analyzed using a New York State database.

Results

After introduction as an ICD-9 code, RSA increased to 39.3% (m = +5.2%/year, r = 0.984). When stratifying by age ≥65, HA decreased to 7.7% (m = -2.8%/year, r = 0.962) while RSA increased to 50.6% (m = +6.4%/year, r = 0.985).

Conclusion

RSA overtook HA as the arthroplasty procedure of choice for proximal humerus fractures. In patients ≥65, RSA passed ORIF as the most prevalent procedure in 2017.

Level of evidence

III, Descriptive Epidemiology Study, Large Database Analysis.

Outcomes following arthroplasty for proximal humeral fractures

Fractures of the proximal humerus are very common and increasing in incidence within an ageing population. The majority of undisplaced fractures can be treated conservatively. Displaced fractures in good quality bone or in the young are considered for surgical fixation. However, displaced and comminuted fractures with or without dislocation, especially in the elderly, cannot be reliably treated with fixation. These patients are generally considered for joint arthroplasty. This review article focuses on the outcome following arthroplasty for proximal humeral fractures.

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.

Impact of scapular notching on reverse total shoulder arthroplasty midterm outcomes: 5-year minimum follow-up

BACKGROUND

The impact of scapula notching on reverse total shoulder arthroplasty (rTSA) clinical outcomes is controversial. The purpose of this study was to conduct a sufficiently statistically powered analysis to quantify the impact of scapular notching on midterm rTSA outcomes.

METHODS

There were 324 rTSA patients with 5 years of minimum follow-up evaluated. Patients were stratified according to the presence of a scapular notch at latest follow-up; radiographs were also assessed at each time point for patients with notching to determine the time for notch grade development. A 2-tailed, unpaired t-test compared preoperative, postoperative, and preoperative to postoperative outcomes between cohorts.

RESULTS

There were 324 patients having an average follow-up of 75.1 months assessed; 47 (14.5%) patients had scapular notching. For scapular notching patients, the average notching grade was 1.7 ± 0.8 (24 grade 1, 15 grade 2, and 8 grade 3). The average time to notch development was 51.4 ± 24.1 months; grade 1, grade 2, and grade 3 notches developed at 49.0 ± 22.1 months, 57.5 ± 22.6 months, and 71.6 ± 15.8 months, respectively. No preoperative differences were observed between cohorts. At latest follow-up, scapular notching patients had significantly worse outcome scores and significantly less active abduction, forward flexion, and strength. Finally, scapular notching patients had significantly more complications, revisions, and humeral radiolucent lines.

CONCLUSIONS

Scapular notching patients had significantly worse clinical outcomes and less range of motion than patients without scapular notching; these differences exceeded the minimal clinically important difference threshold for several outcome metrics. Based on these results, we recommend minimizing scapular notching through patient and implant selection and technique modification.

Primary reverse shoulder arthroplasty for acute proximal humerus fractures: A 5-year long term retrospective study of elderly patients

BACKGROUND

Reverse shoulder arthroplasty (RSA) in complex shoulder fractures is ever more frequently. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures (PHFs) treated with RSA, with and without tuberosities grafting.

METHODS

Between January 2009 and June 2014, 55 patients aged ≥65 years with 3- and 4-part PHFs were treated surgically. Patients' files and the hospital's digital database were reviewed retrospectively with at least 5-year of follow up. We constituted three groups according to the tuberosity consolidation: patients in whom the tuberosities showed anatomic consolidation (Group I) and patients either with secondary displacement of the tuberosities (Group II) or without tuberosity repair (Group III).

RESULTS

The 74% of the repaired tuberosities consolidated in anatomic position. Among range of motion (ROM), we reported that forward elevation, abduction and external rotation were significantly better in Group I than those in Group II-III. Furthermore, quick Dash score and Constant score showed more satisfied results in Group I. Regarding complications, not infection or instability were found in group I. On the other hand, in group II, we reported one patient with deep infection, leading to two steps surgery. In group III, we recorded two patients with instability required implant revision and one with deep infection treated by revision.

CONCLUSION

RSA showed satisfied results even at 5 year follow up. Preservation of the tuberosities in anatomic position improves active forward elevation and external rotation as well as patient satisfaction with less complications.

[Primary fracture protheses and reverse shoulder arthroplasty in complex humeral head fractures : An alternative to joint-preserving osteosynthesis?]

BACKGROUND

The surgical management of complex humeral head fractures has adapted dynamically over the course of the last decade. The primary use of reverse shoulder arthroplasty in elderly patients has gained in relevance due to promising short and middle-term results. Long-term results, however, are still pending. The appliance of anatomical hemiarthroplasty, on the other hand, has lost in significance in favour of osteosynthesis and reverse shoulder arthroplasty.

INDICATIONS

This review article follows the question as to under which circumstances primary fracture arthroplasty reflects an alternative or even a preference to joint-preserving osteosynthesis in the treatment of complex proximal humeral fractures. It also specifies spectrums of indications for anatomical hemiarthroplasty and reverse shoulder arthroplasty.

Complications after surgical treatment of proximal humerus fractures in the elderly-an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating

BACKGROUND

To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques.

METHODS

Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted.

RESULTS

Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions <8 mm, head-shaft displacements >4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer's classification system was not predictive in either group.

CONCLUSIONS

RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.

Is there a relationship between preoperative diagnosis and clinical outcomes in reverse shoulder arthroplasty? An experience in 699 shoulders

BACKGROUND

The influence of diagnosis on outcomes after reverse shoulder arthroplasty (RSA) is not completely understood. The purpose of this study was to compare clinical outcomes of different pathologies.

METHODS

A total of 699 RSAs were performed for the following diagnoses: (1) rotator cuff tear arthropathy (RCA), (2) massive cuff tear (MCT) with osteoarthritis (OA), (3) MCT without OA, (4) OA, (5) acute proximal humeral fracture, (6) malunion, (7) nonunion, and (8) inflammatory arthropathy. All patients had minimum 2-year clinical follow-up (mean, 47 months; range, 24-155 months). Range of motion, Simple Shoulder Test scores, American Shoulder and Elbow Surgeons scores, visual analog scale scores for function, and health-related quality-of-life measures were obtained preoperatively and postoperatively.

RESULTS

The RCA, MCT-with-OA, MCT-without-OA, and OA groups all exhibited significant improvements in all outcome scores and in all planes of motion from preoperatively until a minimum of 2 years postoperatively. The malunion, nonunion, and inflammatory arthropathy groups showed improvements in American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, forward flexion, and abduction. The average changes for all other outcomes and planes of motions were also positive but did not reach statistical significance. After adjustment for age and compared with RCA, female patients with malunion had significantly poorer forward flexion (P < .05), those with OA had significantly better abduction (P < .05), and those with fractures had significantly worse patient satisfaction (P < .05). Among male patients, those with MCTs without OA had significantly worse satisfaction (P < .05).

CONCLUSION

RSA reliably provides improvement regardless of preoperative diagnosis. Although subtle differences exist between male and female patients, improvements in clinical outcome scores were apparent after RSA.

Three- and four-part displaced proximal humeral fractures in patients older than 70 years: reverse shoulder arthroplasty or nonsurgical treatment?

BACKGROUND

The objective of our study was to evaluate the results of surgical treatment by reverse shoulder arthroplasty (RSA) compared with nonsurgical treatment after 2 years of follow-up in patients aged 70 years or older with displaced 3-part or 4-part proximal humeral fractures.

METHODS

Two groups were formed: the RSA group (n = 28) and the nonsurgical group (n = 32). Minimum follow-up was 2 years. We included patients with 3-part or 4-part fractures according to the Neer classification. Main outcome measures were the Constant-Murley score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Subjective Shoulder Value score. An autonomy score, a cognitive assessment score, and a pain score were also measured.

RESULTS

Clinical features in the 2 groups were not significantly different. The Constant-Murley mean score was significantly higher for the RSA group (82.1% vs. 76.8%; P = .03). Amplitudes were all higher in favor of the RSA group (P < .02). There was no significant difference in mean score on the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, the preoperative and postoperative Subjective Shoulder Value score, the autonomy score, the cognitive assessment score, or the pain score in both groups at the last follow-up. The complication rate was higher for the RSA group.

CONCLUSIONS

These results suggest that RSA treatment of proximal humeral fractures with 3-part or 4-part displaced fragments in elderly patients provides better functional outcomes than does nonsurgical treatment. However, the observed clinical difference was relatively small. This solution must be proposed only to patients who have a significant functional demand.

Reverse Shoulder Arthroplasty in Acute Fractures of the Proximal Humerus: Does Tuberosity Healing Improve Clinical Outcomes?

OBJECTIVE

To evaluate the clinical outcomes of reverse shoulder arthroplasty (RSA) in elderly patients with proximal humeral fractures and assess the role of tuberosity healing on the outcome.

DESIGN

Case series.

SETTING

Multicenter clinical study of Level-2 trauma centers.

PATIENTS/PARTICIPANTS

We included 81 patients with a mean age of 78.5 ± 6.5 years (range, 58.5-90.9 years) and a nonreconstructable proximal humeral fracture.

INTERVENTION

Modular reverse fracture shoulder arthroplasty.

MAIN OUTCOME MEASUREMENTS

We determined range of motion, constant score, and the American Shoulder and Elbow Surgeons Shoulder Score as clinical outcomes and evaluated tuberosity healing at 6 weeks, 6 months, 1 year, and 2 years.

RESULTS

Tuberosities healed in most patients; 37 patients had completely healed tuberosities, and 33 patients had partially healed tuberosities, whereas 11 patients had unhealed tuberosities. However, no significant differences were found in the functional outcomes among the 3 groups (P > 0.05).

CONCLUSIONS

Our results with a modular reverse prosthesis confirmed similar constant scores, American Shoulder and Elbow Surgeons Shoulder Scores, and tuberosity healing rates as reported in the current clinical evidence for RSA. We could not confirm that tuberosity healing improved functional outcomes; however, it should be noted that tuberosity healing was assessed using standard radiographs. Nevertheless, our study strengthens the consensus that RSA can be recommended for well-selected elderly patients with complex displaced proximal humeral fractures.

LEVEL OF EVIDENCE

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

National trends in proximal humerus fracture treatment patterns

BACKGROUND

The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment.

AIMS

The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment.

METHODS

The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20 years.

RESULTS

A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012.

DISCUSSION

There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004.

CONCLUSION

Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.

Current concepts in locking plate fixation of proximal humerus fractures

Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.

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.

Impact of scapular notching on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 476 shoulders

BACKGROUND

Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial.

METHODS

We retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded.

RESULTS

Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion (P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines (P = .0896) than patients without scapular notching.

CONCLUSIONS

This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.

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.

Reverse Shoulder Arthroplasty for the treatment of Proximal humeral fractures in the Elderly (ReShAPE trial) : study protocol for a multicentre combined randomised controlled and observational trial

BACKGROUND

Proximal humeral fractures are common in older patients. The majority are minimally displaced and are associated with good outcomes after nonoperative treatment. Poorer outcomes are associated with displaced, multipart fractures. There is no clear benefit from surgical fracture fixation compared to nonoperative treatment. Replacement of the fractured humeral head with a hemiarthroplasty is another treatment option, but has not been shown to be clearly superior to nonoperative treatment or internal fixation. Recently, reverse total shoulder arthroplasty has been used to treat these fractures, particularly in the older population with several case series demonstrating good outcomes. No comparative trial has been performed to test the effectiveness of reverse total shoulder arthroplasty against nonoperative treatment.

METHODS/DESIGN

ReShAPE (Reverse Shoulder Arthroplasty for the treatment of Proximal humeral fractures in the Elderly) is a multicenter combined randomized and observational study. The primary objective is to compare pain and function 12 months post fracture using the American Shoulder and Elbow Society (ASES) score in patients aged 70 years or older with three- and four-part proximal humeral fractures treated by either reverse shoulder arthroplasty or nonoperative treatment. Secondary outcome measures will include the DASH (Disability of the Arm, Shoulder and Hand) score, the EQ-5D (EuroQol Health Survey), the EQ-VAS, pain, radiological parameters and complications.

DISCUSSION

The study will assess the effectiveness of reverse shoulder arthroplasty for complex proximal humeral fractures and thereby guide treatment of a common injury in the older population.

TRIAL REGISTRATION

World Health Organization Universal Trial Number (WHO UTN): U1111-1180-5452 . Registered on 10 March 2016. Australian and New Zealand Clinical Trials Registry (ANZCTR): 12616000345482 . Registered on 16 March 2016.

Reverse Shoulder Arthroplasty for the Treatment of 3 and 4- Part Fractures of the Humeral Head in the Elderly

Background:

Proximal humeral fractures in elderly patients present with severe comminution and osteoporotic bone quality.

Reverse shoulder arthroplasty has lately been proven beneficial in treating patients with complex proximal humeral fractures. The above technique is recommended and has better results in elderly than in younger individuals.

Methods:

We performed a literature search in the databases Pubmed, Medline, EMBASE and Cochrane Library for published articles between 1970 and 2016 using the terms: proximal humerus fractures and reverse shoulder arthroplasty.

Results:

Significant benefits with the use of reverse prosthesis, especially in patients older than 70 years with a proximal humeral fracture, include reduced rehabilitation time as well as conservation of a fixed fulcrum for deltoid action in case of rotator cuff failure.

Compared with hemiarthroplasty and internal fixation, reverse prosthesis may be particularly useful and give superior outcomes in older patients, due to comminuted fractures in osteopenic bones.

However, significant disadvantages of this technique are potential complications and a demanding learning curve.Therefore, trained surgeons should follow specific indications when applying the particular treatment of proximal humeral fractures and be familiar with the surgical technique.

Conclusion:

Although long-term results and randomized studies for reverse prosthesis are lacking, short and mid- term outcomes have given promising results encouraging more shoulder surgeons to use this type of prosthesis in proximal humeral fractures.